LIBRARY OF CONGRESS 



DD000aS537t, 



4 




PAINTED BY SULLY 



EKGR.WED BY CHA S HEATH . 



PUBLISHED BY JOSEPH DELAPLAWE 



mo 'maci 



WM 



LECTURES 



ON THE 



THEORY AND PRACTICE OF PHYSIC, 



DELIVERED IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF THE 
UNIVERSITY OF THE STATE OF NEW YORK. 



BY THE LATE 

DAVID HOSACK, M. D. ? LL. D., F. R. S. 

PROFESSOR OF THE THEORY AND PRACTICE, ETC. AND OP CLINICAL MEDICINE IN THAT 

INSTITUTION. 



WITH AN INTRODUCTORY LETTER, 

BY 

NATHANIEL CHAPMAN, M.D. 

PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF 
PENNSYLVANIA, ETC. 



EDITED BY HIS FRIEND AND FORMER PUPIL, 
HENRY W. DUCACHET, D.D. 

RECTOR OF ST. STEPHEN'S CHURCH, PHILADELPHIA. 



PHILADELPHIA : 
HERMAN HOOKER, CHESNUT STREET. 

1838. 






Entered according to Act of Congress, in the year 1838, by HERMAN 
HOOKER, in the Clerk's Office of the District Court for the Eastern District, 
of Pennsylvania. 



o 



\J 



TO NATHANIEL CHAPMAN, M. IX 

P?*ofessor of the Theory and Practice of Medicine, in the 
University of Pennsylvania. 

Dear Doctor, 

I know not any one to whom I can inscribe these Lectures 
with so much propriety as to yourself. My revered preceptor 
was your friend, and you were his. You have been engaged 
the greater part of your life in teaching the same branch of 
science which he so eloquently taught. And the profession have 
agreed in placing you both in the same rank with the eminent 
men who have been celebrated as the most able and successful of 
our medical teachers. 

I pray you to accept this offering, as the sincere expression of 
my high appreciation of your talents, your eloquence, and your 
learning ; and as the evidence of the personal regard and attach- 
ment of your friend and Pastor, 

HENRY W. DUCACHET. 

Philadelphia, October 9, 1838. 



INTRODUCTORY LETTER. 



Mr Dear Sir : 

I have carefully read the copy of the Lectures of the late 
Professor Hosack, which you had the kindness to send to me. 
The high expectations I had formed of their merits, have been 
fully realised. They embody a very large mass of curious and 
useful information, clearly and agreeably conveyed. Excepting 
some pathological doctrines, I find little in them to which 1 
would object. The practical part I consider sound, or at least, it 
corresponds very much with my own views. Long and exten- 
sively engaged in the profession, and with his acute and discrimi- 
nating mind, he could scarcely fail to arrive at just conclusions in 
whatever regards the management of disease. He deserves, and 
will no doubt rank, among the most authoritative of our writers 
on the subject. You have done well in publishing the work. 
No effort shall I spare to promote its distribution; and I mean 
especially to recommend it to the attention of my class. 
I have the honour to be, dear sir, 

Very faithfully, your friend, &c. 

N. CHAPMAN. 
The Rev. Dr. Ducachet. 

Philadelphia, Oct. 10, 1838. 



PREFACE 



BY THE EDITOR. 



It was my privilege in early life to become the private pupil 
of the late Dr. Hosack. The attachment he conceived for me 
during the years I enjoyed the happiness of his professional in- 
structions, continued uninterrupted ever after; and I possessed 
the honour of his friendship till he died. On the death of my 
beloved preceptor and friend, all his papers, agreeably to his direc- 
tions before his decease, were delivered into my hands. I found 
them, indeed, an immense collection. Among them were manu- 
script notes upon almost every subject, and particularly upon his 
favourite science; and courses of lectures upon almost every 
branch of medicine, for he had taught them all, and had held suc- 
cessively nearly every professorship in the college. 

Dr. Hosack had been a student all his life; he had corresponded 
for years with almost every celebrated literary and scientific cha- 
racter in America and Europe; he had practised physic forty 
years, and seen in that long practice as many patients perhaps as 
any other physician in this country ever did; he had held a high 
rank among the most distinguished of the profession ; and had 
been pronounced by the public voice to be worthy of being 
ranked as a teacher of medicine, with such men as Rush, and 
Wistar, and Physic, and Chapman. He was, therefore, no ordi- 



Xll PREFACE. 

nary man. Abroad, as well as at home, he was regarded and 
honoured as one of the very first physicians of the age, both as a 
man of varied and profound professional attainments, and of great 
practical skill. I was sure that in such a collection of papers, 
made by such a man, there must be much that was valuable ; and 
something that would benefit the medical profession. But it was 
impossible for me, withdrawn as I am from medical pursuits, and 
immersed as I am in the labours of an extensive and responsible 
parochial city charge, to undertake the task of examining them 
all, and judging of their worth. I knew, however, his reputation 
as a lecturer on the theory and practice of physic. I recollected 
well with what eloquence, with what clearness, with what admi- 
rable sagacity, he used to teach that branch while I was at the 
University ; and I knew that his celebrity in that department suf- 
fered no diminution during the subsequent period he continued 
his labours there. I came to the determination, therefore, to 
select his lectures on that subject for the press. I thought that, 
even if the lectures embodied in this volume were of inferior 
value, the public at large, and the profession especially, would be 
gratified to know how medicine was taught by so celebrated and 
experienced a^ teacher. From them they will derive some idea 
of his method, his style, and his system. It is true, as they ap- 
pear, excellent as they are, they do not full justice to his merits. 
The reader has not his frequent and oftentimes eloquent extem- 
pore illustrations: the numerous cases he used to adduce to fortify 
his principles and exemplify his practice; the constantly recur- 
ring anecdotes which gave so much interest and charm to his 
lectures, and served so well to keep up and enliven the attention 
of the audience ; and, worst of all, most of his beautiful classical 
allusions, and of his learned references and quotations, are lost. 
All these were so familiar to him, that they were seldom written. 



PREFACE. Xlll 



The manuscripts would perhaps contain a memorandum here and 
there that would remind one who had often heard him, of the 
many striking and learned illustrations he was in the habit of ad- 
ducing — but could not enable the editor entirely to recover them, 
or to give them with any thing like tolerable accuracy. And 
then, the manner could not be represented. The vivid flashes of 
his keen eye; his fine, manly, commanding voice; his animation 
of delivery, rising, as it often did, to enthusiasm; and his graceful, 
powerful gesticulation — all these are gone. No reader can 
imagine them. He must have heard, and have seen the man, to 
understand what he was in his lecture room. Certainly, if he 
had adopted St. Augustine's rule for preaching, as a rule for his 
prelections, he could not have come nearer the venerable father's 
standard of perfection. There was in his style or his manner 
nothing that appeared like the " obtuse, defor?niter, frigide;" — 
but every thing was done and said, " acute, ornate, vehe?nen- 
ter." — Augttstin. de Doct. Christ, lib. 4. cap. 5. 

But I make no farther apologies for the work, or for myself. 
I commit it to the judgment of the profession, with the confi- 
dence that, whatever may be their decision as to its merits, all 
must acknowledge, or if any refuse to acknowledge, they must 
know, that few, if any, courses of lectures on the theory and 
practice of physic, have been more clear, more learned, more 
practical, or more exactly adapted to the purposes of such a 
course, than these. 

The intelligent reader cannot fail to discover that Dr. Hosack 
was considerably in advance of his own times. He lived to have 
the satisfaction of seeing many of the views and principles for 
which he had contended almost single-handed, adopted exten- 



XIV PREFACE. 

sively in Europe and his native country; and, had he lived a few 
years more, his triumph, I have no doubt, would have been 
greater still. The present volume contains, it will be perceived, 
only his lectures on fevers and the phlegmasia^. These made 
the principal part of the course. Whether the remainder will 
hereafter be published, must depend upon circumstances which 
cannot at present be foreseen or controlled. 



TABLE OP 

CONTENTS 



Page. 

Lecture I. — On the Classification of Diseases, 17 
" II. — Observations and Criticisms upon Dr. Cullen's Classifi- 
cation of Diseases, - - - » -27 

" III. — Of Fevers in general, .... 45 

" IV. — Of Fevers in general, - - - - 56 

" V. — Of Fevers in general, 67 

" VI. — Of Fevers in general, - - - - 79 

" VII. — Of Fevers in general, 93 
" VIII. — Of Fevers in general, and the Evidences of a vitiated 

condition of the Fluids, - 106 

" IX.— The Typhoid State of Fever, - - - 117 
" X. — The Causes of Fever — Predisposing and Exciting 

Causes, ------ 128 

" XL — Exciting Causes of Fever — Exercise, Heat, Cold, 139 

XII.— Causes of Fever— Cold, - - - - 150 

XIIL— Causes of Fever, .... 156 

" XIV. — Causes of Fever — Miasma and Contagion, - - 167 

" XV. — Contagion and its Laws, - - - - 180 

" XVI. — Contagion and its Laws, - 198 

" XVII. — Contagion and its Laws. - - - 215 

" XVIII.— The Proximate Cause of Fever, - - - 227 
" XIX. — The General Treatment of Fever. — Treatment of 

the First Stage, ... 240 
" XX.— The General Treatment of Fever.—Treatment of the 

Second Stage, - - - - - 250 

" XXL— The General Treatment of Fever.—Treatment of 

the Third Stage, 263 

" XXIL— Treatment of the Typhoid State of Fever, - 271 

" XXIIL— Treatment of the Typhoid State of Fever, - 281 

" XXIV. — Divisions and Characteristics of Fevers, - - 298 

" XXV.— Treatment of Intermittents, - - 310 



XVI 



CONTENTS. 



Lecture XXVI. — Remittent Fevers, .... 

" XXVII. — Continued Fevers — Synocha — Characteristic 
Symptoms — Treatment — Synochus vel Typhus, 

« XXVIIL— Dysentery, 

" XXIX.— Dysentery, ----- 
" XXX. — Fevers — Plague, or Pestis Orientalis, 

XXXI.— Yellow Fever, 

" XXXII. — Phlegmasia? — Inflammation, 
" XXXIII. — Phlegmasia? — Inflammation, 
" XXXIV.— Treatment of Inflammation, 
" XXXV. — Phlogosis — Phlegmon — Erysipelas, - 
" XXXVI. — Anthrax, or Carbuncle, the third species of Phlo- 
gosis, -.--_. 
" XXXVII. — Phrenitis, or Inflammation of the Brain, 

XXXVIII.— Ophthalmia, 

XXXIX.— Otitis— Odontitis, - - - - 

" XL.— Parotitis, ------ 

« XLL— Catarrh, ..... 

" XLII. — Trachitis — Cynanche Trachealis, or Inflammation 
of the Trachea, - 
XLIIL— Pertussis, - - - - - 

" XLIV. — Pneumonia, - 

" XLV. — Diaphragmitis and Carditis, 

" XLVI.— Phthisis Pulmonalis, - - - 

" XLVIL— Phthisis Pulmonalis, 

XLVIIL— Phthisis Pulmonalis, - 
" XLIX. — Cynanche Tonsillaris vel Tonsillitis, - 
" L. — Cynanche Maligna, - 
" LI. — Peritonitis, - - - - 

" LIL— Gastritis, - - 

" LIII.— Hepatitis, - - - 

" LIV. — Splenitis — Nephritis — Hysteritis, and Cystitis, 

" LV. — Urethritis, or Gonorrhoea— Orchitis, 

" LVI. — Cruritis, or Phlegmasia dolens, 

" LVII. — Rheumatismus vel Myitis, 

" LVIIL— Arthritis, or Gout, - 

" LIX. — Causes and treatment of Gout, - 



Page. 
327 



334 
345 
356 
372 
383 
394 
405 
413 
422 

438 
446 

460 
474 
486 
494 

511 
530 
538 
553 
557 
568 
577 
593 
559 
604 
609 
615 
634 
645 
653 
664 
674 
685 



LECTURE I. 



ON THE CLASSIFICATION OF DISEASES. 



The immediate object of the course of lectures upon which 
we are now to enter, is the exhibition of the nature, causes, and 
cure of diseases. But when we look at the multitude of dis- 
eases to which the human frame is liable, where shall we be- 
gin — what shall be our order of proceeding? Let us in the first 
place endeavour to arrange into some order the numerous ob- 
jects which are to come before us. This is the business of 
nosology.* 

Nosology may be defined to be an arrangement of diseases, 
in such order as will be best calculated to give us a knowledge 
of them, and of the most prominent characteristics by which 
they are to be distinguished from each other. 

Where many objects are presented to our notice, you will 
readily admit some order becomes necessary to a correct view 
of them; and especially to enable the mind to retain the 
impression of them. In natural history the objects are so nu- 
merous that the memory could not possibly contain them with- 
out the aid of a system, or some methodical arrangement; 
especially the numerous objects of the vegetable kingdom. 
There are now upwards of thirty thousand species of plants 
well described by botanists, and distinguished from each other. 
But without some classification of those objects, what memory 
could retain them? — They must be associated, to be remem- 
bered. 

* Nosology is a term composed of two Greek words — vctre? which signifies 
disease, and xo^o?, discourse. 
3 



18 LECTURE I. 

In the animal or the mineral kingdoms, the objects are not 
so numerous : nevertheless arrangement in those departments 
of natural science is no less useful and necessary in acquiring 
a knowledge of the various objects they embrace. In a word, 
no art or science, where the objects of which it treats are nu- 
merous, can be acquired without it: for none can be clearly 
treated of or communicated without arrangement. 

In describing diseases, a somewhat similar or analogous 
mode of arrangement has been adopted, and has been formed 
upon the resemblances and distinctions which are found to exist 
between them. This mode of arranging diseases was first 
suggested (at least practically suggested) by Sydenham and 
Baglivi. They were the first who proposed the distribution of 
diseases upon similar principles with those afterwards adopted 
by botanists — into classes, orders, genera, and speeies; and 
they were the first who connected with them characteristic 
definitions, in which are detailed the distinctive or pathogno- 
monic symptoms of each individual form of disease. 

I may here remark that various other modes of arrangement 
have been adopted, and have had their abettors ; but they have 
all given place to that which is now most generally pursued as 
founded upon the distinctive symptoms of diseases. 

Aretseus and Ccelius Aurelianus divided diseases according 
to their duration, into acute and chronic. 

Johnston, Sennertus, and Morgagni, and I may add Dr. 
Mead in his "Medical Precepts and Cautions," distribute dis- 
eases according to their seat — into those of the head, chest, 
belly, limbs, &c; making the anatomical division of the body 
the basis of their arrangement. Indeed the late physiological 
system of Dr. Good is founded upon this principle; and the 
same is adopted by Dr. Chapman, in the school of Pennsyl- 
vania. 

Boerhaave, Riverius, and Hoffman, again, adopted a different 
principle of arrangement. They divided diseases according to 
the supposed causes from which they were produced. This 
system of arrangement has been denominated the ^Etiological 
arrangement, from the term a ^;«, signifying a cause. 

But all these several methods have yielded to that now ge- 
nerally in use, founded upon the pathognomonic symptoms, and 
which, as most true to itself, is now considered as the most wor- 



CLASSIFICATION OF DISEASES. 19 

thy of attention. For, notwithstanding the influence which cli- 
mate, constitution, temperaments, and peculiar frame of body, 
may have in varying or modifying the character of diseases, 
the great features or leading symptoms by which any individual 
disease is attended, are so constant and strongly marked, that 
they furnish us with the best possible basis of an arrange- 
ment by which diseases are to be distinguished and ascertained, 
and which is essentially necessary before we attempt to inves- 
tigate their nature or their causes — or prescribe for their 
relief. « - 

The hint suggested by Sydenham, was first realised by the 
learned Sauvages, the professor of botany and medicine, at 
Montpelier, — the Boerhaave of Languedoc, as he was sur- 
named, such was his learning and so extended his reputation. 
Sauvages first published the outlines of his plan in 1731, in a 
little modest duodecimo volume, under the title of " Nouvelles 
Classes de Maladies," but not until he had submitted his inten- 
tion to the judgment of Boerhaave. In this edition, he only 
descended to the genera. In 1763, four years before his death, 
he published a new and more extensive edition in five volumes 
octavo, embracing the species of diseases. This second edi- 
tion may be considered as the first in reality ; and upon it he 
had patiently laboured upwards of thirty years. So important 
was the subject of nosological arrangement in the opinion of 
the great and learned: Sauvages. 

But his last and still more complete edition, which he had 
prepared with the utmost care, he did not live to publish. It 
appeared in 1768, the year after his death, in two volumes 
quarto. He died 19th February, 1767, aged sixty-one. A 
methodical arrangement of diseases was next followed by 
Linnaeus in 1763. A pupil of Linnaeus had published an outline 
of his method in 1759. Afterwards succeeded Vogel, the pro- 
fessor at Gottingen. 

In 1764, Vogel published a close approximation to the work 
of Sauvages, but containing much personal observation of the 
phenomena of diseases. His work is entitled " Definitiones 
Generum Morborum." This appeared at Gottingen in 1764, 
in a single octavo volume. These were followed by the 
" Systema Morborum Symptomaticum" of Sagar, the pro- 
fessor at Vienna, published in 1776, which is another modifi- 



20 LECTURE I. 

cation of the system of Sauvages. Dr. M'Bride also, has left 
an imperfect arrangement of diseases, which, on account of 
the skill he has displayed in the arrangement of his genera and 
species, deserves the attention of the nosologist. 

Lastly appeared, the Nosologia Methodica of Dr. Cullen, 
whose classification has been considered as the most perfect of 
any systematic arrangement that has yet been published. 

I pass over altogether, the visionary views of Brown and 
Darwin, on this subject. 

In 1731, Sauvages, as I before remarked, first attempted his 
system of arrangement, but he did not give it publicity, until 
he had matured it during thirty years' observation. It is, ac- 
cordingly, the best that appeared prior to that of Dr. Cullen. 

Sauvages divided diseases into ten classes, which compre- 
hended upwards of forty orders, more than three hundred 
genera, and an innumerable host of species. 

No wonder Monsieur De Rette exclaimed, " Quel nombre 
prodigieux d'ennemis." This number of species was diminish- 
ed by Linnseus and Vogel, who succeeded him. The classifica- 
tion of Sauvages, notwithstanding the labour he bestowed upon 
it, is not free from several errors and imperfections. Some of 
these it possesses in common with all other attempts to arrange 
into classes the works of nature ; for anomalies occur in dis- 
eases as in the objects of natural history, which disturb the 
unity of artificial arrangements, uniting dissimilar genera, and 
rendering necessary the separation of others which a general 
analogy would connect. Other imperfections, however, in the 
classification of Sauvages appear to be the result of a want of 
accurate attention or discrimination. It is true, that Felix 
Platerus, about the end of the sixteenth century, and the begin- 
ning of the seventeenth, (his work was published in 1602, under 
the title of Praxis Medica,) had made an attempt to arrange 
diseases upon the symptomatic plan, but it was so imperfectly 
executed as not to be considered as a system of nosology. Yet 
it is very possible that Sydenham availed himself of it — he was 
at least actuated by the same quickening spirit, for his various 
treatises and epistles, are a practical comment upon Plater's 
principle : and it is probable too, that Sauvages took some 
hints from it, imperfect as it was. They are, however, few and 
but of little importance. 



CLASSIFICATION OF DISEASES. 21 

Mr. Good considers Platerus, as " the morning star that first 
glimmered in the hemisphere of symptomatology, as Servetus 
was in that of the circulation of the blood. The light of both," 
he adds, " was feeble and tremulous, but it twinkled in the 
midst of darkness and led on to the brightness of day." 

But to Sydenham, in my opinion, Sauvages was most in- 
debted for the full illustration of that symptomatic method 
which constituted the great improvement that this subject has 
received at his hands, and which has been matured by his suc- 
cessors — particularly by Dr. Cullen. 

Linnseus of Upsal, the great botanist, and who had been 
much occupied in devising arrangements of the vegetable king- 
dom — his favourite department of science, and Vogel of Got- 
tingen, as I said, gave the world two other systems ; but they 
followed that of Sauvages so closely, that medicine has re- 
ceived but little benefit from their labours. Indeed, in the 
opinion of Dr. Cullen, both Linnseus and Vogel have embar- 
rassed nosology — the former by the introduction of terms that 
are unnecessary — the latter by those which are actually frivo- 
lous and improper. 

In the year 1817, another system appeared which, although 
rejected by the College of Physicians, attracted much notice 
from the learned in Great Britain. It is the physiological sys- 
tem of that distinguished scholar and surgeon, Dr. Good of 
London. He calls it a physiological system, thereby denoting 
that it is founded upon a physiological view of the diseases it 
describes. 

So far as our purpose is concerned, it is liable to two promi- 
nent objections. 

1. Diseases of the same nature as it regards their general 
character, are treated of in each and every class, merely be- 
cause they happen to be seated in different parts of the body. 

2. His terminology is new. — This is not wanted. The truth 
is, he is a better scholar than physician. 

All nosological arrangement has been objected to by some 
physicians. But the abuse of it is certainly no argument 
against its use. 

The great objection that has been generally alleged against 
nosology is, that each systematic has been guided by his own 
theoretical or rather hypothetical notions. Medical science 
3* 



22 LECTURE I. 

has certainly been injured in this respect, in all ages, by the 
undue application of the predominant and fashionable sciences 
to explain the laws of the animal economy. It has been in- 
jured even by the exact sciences, mathematics and mechanics, 
which were applied to explain the functions of the body, after 
Sir Isaac Newton had rendered those branches of study po- 
pular in the world, by the numerous improvements he intro- 
duced into them. 

While the mechanicians (as in the examples of Pitcairn and 
Keill,) calculated the force of the stomach in the digestion of 
the food, or the power of the heart and arteries in circulating 
the blood — while they measured the momentum of the fluids, 
together with the shape and dimensions of the tubes they move 
in, as if belonging to an hydraulic machine — and while the 
chemists in like manner, examined the change of properties 
those fluids acquire by such motion through the body, and un- 
dertook to explain secretion and excretion by their art, they 
forgot that the vital principle also, controls and governs all the 
phenomena of the living body, and that animation is the predo- 
minant power in our system. 

Metaphysics have also been applied in the same exclusive 
manner in accounting for the phenomena which our bodies 
exhibit, both in the healthy and the morbid state. Hence, the 
anima medica of Stahl, and the errors it has introduced. 
Chemistry in like manner has injured medicine, by the undue 
extension of the discoveries of Dr. Black, Priestley, and La- 
voisier, in explaining the phenomena of diseases. Even elec- 
tricity was had recourse to by its ardent cultivators, to account 
for the phenomena of disease. According as the electric fluid 
predominated or- was diminished in our system, whether plus 
or minus, so were the characters of its diseases. And these 
were to be removed by restoring the equilibrium. Shaw's sys- 
tem of medicine is exclusively founded on these principles. It 
is surprising to observe the inordinate attachment which parents 
manifest to these children of the imagination ! — And it happens 
too that frequently, in proportion to the deformity with which 
they come into the world, will be the efforts made to perpe- 
tuate their existence. 

As with the electrician, so it is with the mechanical philoso- 
pher, the mathematician, the metaphysician, and the chemist, in 



CLASSIFICATION OF DISEASES. 23 

the application of their doctrines to medicine. It is not in- 
tended to depreciate the utility of those departments of know- 
ledge to the physician — their use and their application must be 
admitted by all — but, like the vires naturae medicatrices, they 
should be the handmaids and not the mistresses of our science. 
They should follow, but never exclusively direct, our researches. 
While some eminent physicians in consequence of this abuse 
of the application of the different sciences to medicine, are 
disposed to decry nosological arrangement, let us not go to the 
other extreme, by rejecting it altogether. 

The object of nosology is not merely to assemble diseases — 
it also furnishes the characteristic, or more prominent, symptoms 
by which diseases are designated : and thence we are led 
readily to distinguish them one from the other. 

But we are not only by such arrangement, led to the know- 
ledge of the pathognomonic symptoms of each family or genus 
— our inquiries immediately extend to the species or members 
of each family, and even the varieties it exhibits under parti- 
cular circumstances. This is not all — knowing the peculiar 
character of diseases, we are equally induced to ascertain and to 
discriminate between the various remote causes from which 
those diseases severally proceed ; and thence we ascend to a 
knowledge of the more immediate or proximate cause — our 
great guide in the cure, inasmuch as such assemblages of dis- 
eases lead to general principles in practice. We may say, 
therefore, of diseases as of style or painting, according to 
Ovid's description of the twin sisters, 

" Facies non omnibus una, nee diversa tamen." 

They are not all the same — yet they are not so widely dif- 
ferent, but that they have some common principles by which 
they are connected. Yet, according to circumstances they 
differ in their grade, or, perhaps, in their specific character; and 
thence demand each its peculiar treatment. We see this illus- 
trated in croup. This disease, and very lately too, was consi- 
dered by some as a malignant species of cynanche forbid- 
ding the lancet. See Dr. Bard's dissertation. See also, Fo- 
thergill, Douglas of Boston, and Johnston of Worcester, who 
have all treated of the malignant ulcerous sore-throat, which 



24 LECTURE I. 

frequently exhibited in its termination the symptoms of croup. 
Dr. Cullen understood it, and has given Dr. Bard's work on 
croup, its proper place in his nosological arrangement. He 
considered it as in reality not a primary croup, but in its com- 
mencement the malignant ulcerous sore-throat, which ended in 
croup. In the treatment, therefore, they were governed by its 
primary character, and the cause from whence it originated. 

Again, by others, it has been considered as a spasmodic 
disease ; but since that period it has been satisfactorily shown, 
that its spasmodic symptoms arise from the sensibility of the 
part in which the inflammation takes place. Accordingly, the 
disease, with all the various characters which it assumes, is 
now well understood. We know its symptoms, causes, species, 
whether idiopathic or symptomatic ; and thence the general prin- 
ciples of treatment become apparent. So of hysteritis. There 
are two species ; one purely inflammatory, the other sympto- 
matic of a typhoid state of body — each calling for its peculiar 
treatment. 

So of pneumonic inflammation. The pathognomonic symp- 
toms are " fever, pain in some part of the chest, dyspnoea 
and cough." These combined, constitute pleurisy, and call for 
active depletion, venesection, &c. Again ; take away the 
cough and fever, and you have a rheumatic affection of the 
muscles of the ribs. Venesection now, in some instances, is 
contraindicated and even injurious. — Or take away the pain — 
the cough may be symptomatic of other diseases, as typhus 
fever, indigestion, worms, &c, and the treatment must be 
directed accordingly. 

If, then, it is important to distinguish diseases for the pur- 
poses of practice, it is no less necessary to class and arrange 
diseases for the purpose of knowing those distinctions as sub- 
servient to practice ; and these, as Dr. Cullen has justly ob- 
served, can only be explained by a rightly constructed nosolo- 
gical method. And, in the language of Linnaeus, " System is 
the Ariadnean thread, without which all is confusion." 

Our countryman, Dr. Rush, objected to all nosological ar- 
rangement as injurious, yet he himself had his own unitarian 
system. He considered all the varieties of diseases, in what- 
ever shape they may appear — in whatever part of the system 
they may be seated ; whether in the solids or fluids, in the nerves, 



CLASSIFICATION OF DISEASES. 25 

the blood-vessels, or absorbents, as one and the same morbid 
action, viz. excitement, &c. To use his own language, " Dis- 
ease is unit ;" i. e. a modification of the same diseased action 
of the system. — Not only is his nosology thus limited, but his 
materia medica contains but one remedy ; that is, that the reme- 
dies proper for those diseases are to be considered as having 
all the same general action upon the system. 

Notwithstanding Dr. Rush's late attachment to this unitarian 
doctrine in medicine, he formerly was as warmly attached to 
the Cullenian arrangement. I remember the day when he re- 
commended to his pupils, for I was at that time one of them, 
to commit even the definitions of Dr. Cullen to memory as he 
should do the rules of grammar in learning the Latin tongue, 
or the first axioms and propositions of Euclid in learning ge- 
ometry. " Let me advise you," he then said to his pupils, " never 
to prescribe until you have investigated the disease and given 
it its proper place, its class, its order, its genus and species." 

I hope I have profited by his instruction, and that I shall be 
permitted to adhere to his first lessons as more correct than his 
last doctrines on this subject : but let us recollect that even his 
unitarian doctrine of diseases calls for, and he has accordingly 
made, subdivisions denoting the various grades, forms and seats 
of diseases, or in other words, denoting the peculiar characters 
of individual diseases, and their associations arising out of those 
peculiar characters. He himself admits, " that in applying the 
principles of physiology, pathology and therapeutics to the 
practice of physic, some order is necessary in speaking of in- 
dividual diseases." Indeed, we may say of the physician what 
Dr. Rush says of a philosopher, that he can no more be formed 
by a fortuitous concourse of ideas than a world can be pro- 
duced by a similar concourse of atoms. 

As it is not my intention to go into a very minute history of 
each disease, but to confine myself to the characteristic or pa- 
thognomonic and diagnostic symptoms as essentially subservi- 
ent to practice, I shall insist the more on those symptoms as 
they are detailed in such system of nosology, referring you for 
the more ample details to the best books on each subject. 

For all controversial matter too, upon the rationale of the 
causes of disease, I shall refer you to books also — when you 
have gotten the facts, I shall refer you to Brown, Cullen and 



26 LECTURE I. 

Darwin for their several speculations. My object is to give 
you the facts I have been enabled to collect, either from books, 
my own observation, or other sources ; and these I shall ar- 
range in the best order I can devise, both as it regards your 
remembrance of them and the general principles to which they 
may give rise. The inductive system, as far as I am capable 
of distinguishing between truth and error, shall be strictly pur- 
sued upon every subject of which we shall treat ; that is, I 
shall lay before you the facts that I believe to be well established ; 
and you shall draw the conclusions to which they lead ; or ra- 
ther facts will draw their own conclusions : for as I have said 
before, facts, well assembled, constitute general truths or prin- 
ciples. This leads me to make some remarks on the arrange- 
ment of Dr. Cullen, which is now most generally received by 
the medical world. — As to the nutshell system of Brown, divid- 
ing diseases into sthenic and asthenic, like that of Thessalus 
of old, into strictum and laxum, I altogether reject it as un- 
worthy of our notice for the purposes of practice. — Like the 
unitarian doctrine of Dr. Rush, it is saying little more than 
" that disease is disease." 

In the arrangement which I have adopted, you will find that 
I am neither unitarian nor methodist; but an eclectic, or uni- 
versalist, if you please ; and, like the eclectics of old, I shall 
take truth, at least what I believe to be truth, from all their 
systems, wheresoever I can find it. My motto shall be the 
language of Pliny: " Auctorem neminem unum sequar sed ut 
quemque verissimum in qua parte arbitrabor."— Plin. Hist. 
Nat lib. iii. 



27 



LECTURE II. 



OBSERVATIONS AND CRITICISMS UPON DR. CULLEN'S CLASSIFY 
CATION OF DISEASES, &c. 



As I remarked yesterday, the same principles of arrange- 
ment that have been adopted by the naturalist, in the disposal 
of the numerous objects of natural history, have been made 
use of by physicians in the distribution of diseases. They are 
assembled into parcels or classes, according to some manifest 
or well known circumstances, in which the members of each 
class have a resemblance, or possess properties or characters 
in common. Each class is next arranged into subordinate di- 
visions, in which each sub-division is designated by some 
marks peculiar to itself. Those divisions of the classes are 
called orders. Each order again is made up of families called 
genera, possessing characteristic marks by which every such 
genus is distinguished from its congeners. Each family or 
genus, again consists of members denominated species — each 
species being designated by some characteristic marks that 
separate it from its fellow members of the same family. 

Let us now by this standard, examine Dr. Cullen's arrange- 
ment, which has been most approved. To understand what I 
shall say, you must have before you a synopsis of his system, 
which I present you accordingly. 

DR. CULLEN'S SYSTEMATIC ARRANGEMENT OF DISEASES, 
CLASS I.— PYREXLE. 
Ord. I. — Febres. 
§ 1. Intermittentes. § 2. Continues. 

1. Tertiana. 4. Synocha. 

2. Quartana. 5. Typhus. 

3. Quotidiana. 6. Synochus. 



28 



LECTURE II. 



7. Phlogosis. 

8. Ophthalmia. 

9. Phrenitis. 

10. Cynanche. 

11. Pneumonia. 

12. Carditis. 

13. Peritositis. 

14. Gastritis. 

15. Enteritis. 



25. Variola. 

26. Varicella. 

27. Rubeola. 

28. Scarlatina. 

29. Pestis. 



35. Epistaxis. 

36. Haemoptysis. 



39. Catarrhus. 



41. Apoplexia. 

43. Syncope. 

44. Dyspepsia. 

47. Tetanus. 

48. Trismus. 

49. Convulsio. 

50. Chorea. 

51. Raphania. 

52. Epilepsia. 

53. Palpitatio. 

54. Asthma. 

55. Dyspnoea. 



64. Amentia. 

65. Melancholia. 



68. Tabes. 



§ 1. Adiposes. 

70. Polysarcia. 

§ 2. Flatuosa. 

71. Pneumatosis. 

72. Tympanites. 

73. Physometra. 

§ 3. Aquosa. 

74. Anasarca. 

75. Hydrocephalus. 



Ord. II. — Phlegmasia. 

16. Hepatitis. 

17. Splenitis. 

18. Nephritis. 

19. Cystitis. 

20. Hysteritis. 

21. Rheumatismus. 

22. Odontalgia. 

23. Podagra. 

24. Arthropuosis. 
Ord. III. — Exanthemata. 

30. Erysipelas. 

31. Miliaria. 

32. Urticaria. 

33. Pemphigus. 

34. Aphtha. 

Ord. IV. — Hemorrhagic. 

37. H emorrhois. 

38. Menorrhagia. 

Ord. V. — Profluvia. 

40. Dysenteria. 

CLASS II.— NEUROSES. 
Ord. I.— Comata. 

42. Paralysis. 
Ord, II. — Adynamic 

45. Hypochondriasis, 

46. Chlorosis. 

Ord. III. — Spasmi. 

56. Pertussis. 

57. Pyrosis. 

58. Colica. 

59. Cholera. 

60. Diarrhoea. 

61. Diabetes. 

62. Hysteria. 

63. Hydrophobia. 

Ord. IV. — VesanijE. 

66. Mania. 

67. Oneirodynia. 

CLASS III.— CACHEXIA. 
Ord. I. — Marcores. 

69. Atrophia. 
Ord. II. — Intumescentic 

76. Hydrorachitis. 

77. Hydrothorax. 

78. Ascites. 

79. Hydrometra. 

80. Hydrocele. 
§ 4. Soli da. 



81. Physconia. 

82. Rachitis. 



dr. cullen's classification. 



29 



83. Scrofula. 

84. Syphilis. 

85. Scorbutus. 

86. Elephantiasis. 



91. Caligo. 

92. Amaurosis. 

93. Dysopia. 

94. Pseudoblepsis. 

95. Dyseccea. 



Ord. III. — Impetigines. 

87. Lepra. 

88. Framboesia. 

89. Trichoma. 

90. Icterus. 

CLASS IV.— LOCALES. 



Ord. L- 



-DySjESTHESIjE. 

96. Paracusis. 

97. Anosmia. 

98. Agheustia. 

99. Anaesthesia. 



Ord. II. — Dysorexi^e. 

§ 1. Appetitus Erronei. 105. Nostalgia. 

100. Bulimia. 

101. Polydipsia. § 2. Appetitus deficientes. 

102. Pica. 106. Anorexia. 

103. Satyriasis. 107. Adipsia. 

104. Nymphomania. 108. Anaphrodisia. 



109. Aphonia. 

110. Mutitas. 

111. Paraphonia. 

112. Psellismus. 



116. Profusio. 

117. Ephidrosis. 

118. Epiphora. 

122. Obstipatio. 

123. Ischuria. 

124. Dysuria. 

127. Aneurisma. 

128. Varix. 

129. Ecchymoma. 

130. Scirrhus. 

131. Cancer. 

132. Bubo. 

133. Sarcoma. 



141. Hernia. 

142. Prolapsus. 

144. Vulnus. 

145. Ulcus. 

146. Herpes. 

147. Tinea. 



Ord. III. 



-Dyscinesi^e. 

113. Strabismus. 

114. Dysphagia. 

115. Contractura. 



Ord. IV. — Apocenoses. 

119. Ptyalismus. 

120. Enuresis. 

121. Gonorrhoea. 

Ord. V. — Epischeses. 

125. Dyspermatismus. 

126. Amenorrhoea. 



Ord. VI. — Tumores. 

134. Verruca. 

135. Clavus. 

136. Lupia. 

137. Ganglion. 

138. Hydatis. 

139. Hydarthrus. 

140. Exostosis. 

Ord. VII. — Ectopia. 

143. Luxatio. 

Ord. VIII. — Dialyses. 

148. Psora. 

149. Fractura. 

150. Caries. 



He divides all diseases, you will perceive, into four classes, 
viz. 1. Pyrexiae ; 2. Neuroses ; 3. Cachexia? ; and 4. Locales. 

4 



30 LECTURE II. 

His first class, Pyrexiae, is a bad class ; and independently 
of the incorrectness of his definition of it, should be expunged. 
Under this head, you will observe, Dr. Cullen professes to in- 
clude all diseases attended with fever or increased heat, as the 
term pyrexiae imports, being derived from the Greek word ™§, 
signifying fire. 

In the first place I remark, then, this class is objectionable, 
as it includes the order haemorrhagiae, which are not necessa- 
rily, nor are they always or even generally, febrile diseases. 
On the contrary, they are frequently without fever, especially 
hemorrhage from the uterus, the liver, lungs, bowels, haemor- 
rhoids, and the haemorrhage in scurvy. Indeed, I scarcely know 
any case of haemorrhage that is febrile, unless it may prove so 
in its effects : even then, fever is an accidental and not a ne- 
cessary attendant. 

2. It excludes other diseases that are acknowledged to be of 
a febrile character, which Dr. Cullen has distributed in his other 
classes. 

Pertussis, 56, which is usually febrile, he has placed among 
the Neuroses. 

Syphilis, dropsy, placed in Cachexiae, are oftentimes febrile. 
So, too, are obstipatio, 122 ; vulnus, 144 ; fractura, 149 ; her- 
nia incarcerata, 141 ; hydarthrus, 139 — all which he makes 
Locales. 

Observe, I do not object to the place assigned to these dis- 
eases ; but as Dr. Cullen set out with the intention of assembling 
all febrile or pyrexious diseases in the same class, he should 
either have adhered to his original intention, or he should not 
have made a class of this extensive character, as he has done 
his pyrexiae. 

Again — 3dly. This class is defective, it wants a number of 
inflammatory diseases — it wants diaphragmitis, a distinct 
species ; periostitis also is wanting. 

It wants phlegmasia dolens, otitis, odontitis, mastitis. In- 
deed, it might almost be said that this class of Pyrexiae is so 
general, that almost every disease might be included in it. 
For scarcely a disease exists that is not sometimes attended 
with fever. The class pyrexiae is, therefore, too general to 
stand as a class. 

The second class, Neuroses, is a good class and should have 



dr. cullen's classification. 31 

a place in every system of arrangement ; but constructed as it 
is by Dr. Cullen, it is exceptionable. 

The first objection to it is, that it contains some diseases in 
which the blood-vessels and secretions are manifestly affected, 
and in which the nervous system is not primarily affected, viz. 
pertussis, 56. This disease comes on like a common catarrh — 
is a febrile disease, and properly one of the Pyrexiae. 

2dly. This class contains some diseases which chiefly consist 
of increased natural evacuations ; as, cholera, 59 ; diarrhoea, 
60; diabetes, 61. These are every thing else but Neuroses, 
and belong to a totally different class of diseases, not at all 
provided for by Dr. Cullen. 

These diseases should not be placed in the class Neuroses, 
because of a particular symptom — otherwise every disease 
might be included in this class ; for every disease exhibits some 
affection of the nervous system. 

Nor should they be placed in Dr. Cullen's order of profluvia ; 
because these diseases are generally without fever ; whereas 
his profluvia have fever, and are in his class of pyrexious dis- 
eases. 

3dly. Dr. Cullen's Neuroses contains some diseases as genera 
and species, which are only symptoms of other diseases. 

Chlorosis, 46, is symptomatic of amenorrhcea or suppres- 
sion of the menses, or a species of dyspepsia, but not an idio- 
pathic disease. 

Pyrosis, 57, is only a modification of indigestion, one of the 
symptoms of dyspepsia, but not a disease in itself. And dyspnoea, 
55, is in like manner symptomatic of catarrh, pneumonia, 
hydrothorax, an excessive quantity of fat, angina pectoris, 
and other affections of the chest, but is not an idiopathic dis- 
ease ; and therefore should be expunged. Indeed, it should 
have no place in any system, as it is only a symptom, and not 
itself a disease. 

4thly. This class is defective, as it does not contain many 
diseases which are exclusively nervous, and are arranged in 
the other classes, — such as amaurosis, 92, of the first order 
of locales, and the other paralyses of the senses, as 96, 97, 
98, &c. paracusis, anosmia, agheustia, aphonia, 109. 

5thly. It does not contain all the diseases of the mind — as 



32 LECTURE II. 

nostalgia, 105, which is a species or a peculiar form of melan- 
cholia. See second order of class Locales, where it is most 
strangely located. 

6thly. The class Neuroses does not contain the affections of 
the stomach, connected with dyspepsia, 44, as the dysorexise, 
thrown into the second order of class Locales, in which he sepa- 
rates bulimia, 100; pica, 102; anorexia, 106; from dyspepsia, of 
which they are modifications or symptoms, and with which, 
therefore, they should be associated. 

The third class, Cachexias — meaning diseases of a bad habit 
of body. This class, as its name imports, ought to include all 
diseases which arise from a vitiated or bad habit of body. 
Does it do so 1 No — it does not ; it is defective. 

1. It does not contain among his intumescentise or swell- 
ings, all the dropsical diseases, as hydrops pericardii, hydrops 
ovarii, hydrops articuli. 

2. It wants mollities ossium ; fragilitas ossium ; lithiasis or 
calculus ; the yaws, or framboesia ; and the form of syphi- 
lis denominated laanda Africana, as described by Dr. Winter- 
bottom. 

3. This class is not only defective — it is faulty. It contains 
some eruptive diseases, as in the third order, impetigines, as, 
elephantiasis, 86 ; lepra, 87 ; frambcesia, 88 ; while other erup- 
tive diseases are dispersed in other classes, some in the first 
class among the exanthemata, as small-pox. Others again are 
in the fourth class Locales, viz. tinea, 147 ; herpes, 146 ; psora, 
148 ; and which are not always local or confined to a part. 

These eruptive diseases should all be associated in one class, 
in order that a comparative view may be taken of them, and 
that some general principles may be derived from such asso- 
ciation, and thereby lead to some general results as to their 
treatment. 

4. The order impetigines contains diseases which are 
without eruptions, yet they are placed here under the head of 
scabby or eruptive diseases, as the term impetigines imports, 
viz. scrofula, 83, which is not eruptive ; syphilis, 84, which 
is not invariably so ; icterus, 90, which is a suppression or 
retention of bile, in which there is no eruption, but only a yel- 
lowness of skin. This surely is not sufficient to justify its 



DR. CULLEX'S CLASSIFICATION. 33 

place here ; if it is, then yellow fever, and bilious remittent, and 
hepatitis, should be here too. 

Class 4 — Locales. In this class too, we shall find a very 
objectionable arrangement. 

1. It contains in the first and third orders, several of the 
paralyses, (viz. in the first order, amaurosis, 92 ; paracusis, 
96 ; anosmia, 97 ; agheustia, 98 ; anaesthesia, 99 : and in the 
third order, aphonia, 109; mutitas, 110; dysphagia, 114;) 
which, though they are partial, yet are of the same nature and 
character with the general palsies, and should be arranged 
with them among the Neuroses, especially too, as they call for 
the same general principles of treatment. 

2. It contains nostalgia, 105, which is a disease of the mind 
and manifestly belonging to the class Neuroses. — Upon what 
principle, then, can it be placed among the local diseases ? 

3. It contains many diseases which are of a general, not 
of a local nature, viz. obstipatio, 122; ischuria, 123; amenor- 
rhcea, 126 ; which belong to a totally different class of dis- 
eases — the class of suppressiones, which have no distinct or 
appropriate place in Dr. Cullen's system. If these diseases or 
other suppressions of natural discharges have a place in the 
class Locales, upon the same principle all the phlegmasia have 
equal claims to this class. 

4. The class Locales contains many diseases which should 
be constituted a different class, in which excessive discharges 
are brought together — another class, not provided for by Dr. 
Cullen — profluvia, viz. profusio, 116; this should be associated 
with hemorrhages; ephidrosis, 117; epiphora, 118; ptyalis- 
mus, 119; enuresis, 120. These being general, not local dis- 
eases, have no business here, but should belong to the class of 
Profluvia, or increased discharges. 

5. It contains gonorrhoea virulenta, 121, and hydarthrus, 
139, which belong to the inflammatory diseases, the phlegma- 
siae — excepting gonorrhoea, properly so called — I mean in- 
creased seminal discharges, according to its etymology: that 
should be one of the profluvia. 

6. It contains also eruptive diseases, viz. herpes, 146 ; tinea, 
147 ; psora, 148, which should not be separated from the other 
eruptive or cutaneous diseases. He even, as before remarked, 
separates them from lepra, and other eruptive diseases in the 

4* 



34 LECTURE II. 

third class, as well as from urticaria, of the first class, but 
which should all be associated in one class of cutaneous dis-. 
eases. 

7. It contains contractura, 115, as a distinct disease, which 
is either an original deformity, or is symptomatic of some pre- 
vious injury. In like manner he has bubo, 132 ! This too, is 
a mere symptom — it is symptomatic of syphilis, of pestis, 
scrofula, phlogosis. 

8. It contains many diseases which belong to dyspepsia, 
being symptomatic of it, or so nearly allied, that they should 
at least be associated with it in the same class, and not among 
the Locales. See second order of Locales, viz. bulimia, 100 ; 
pica, 102; anorexia, 106; adipsia, 107; polydipsia, 101. 

9. This class is defective, it wants several genera, viz. 
bronchocele, fungus haematodes, polypus of the nose and 
throat. 

I shall now proceed to make a few remarks upon the sub- 
ordinate arrangements of Dr. Cullen's classification. 

(1.) I observe that he has no remittents in his first order — 
confining himself entirely to the intermittent and combined 
forms of fever— whereas remittents, especially in warm cli- 
mates, are certainly altogether distinct from intermittents in 
their character, and require a totally different treatment. They 
therefore should have an appropriate place in a system of prac- 
tical nosology. In this country this distinction is essentially 
important. 

2. Dr. Cullen too, as you will perceive in his section called 
continued fevers, distinguishes typhus from synochus, making 
them two distinct genera ! — yet in his notes he acknowledges 
he cannot distinguish between them. " Inter typhum tamen et 
synochum limites accuratos ponere non possum ; et an revera 
pro diversis generibus habenda vel positis diversis, utri eorum 
synonima auctorum referenda sunt, dubito.' , 

3. Dr. Cullen's febres do not embrace the plague, 29, one of 
the most formidable febrile diseases that man can be afflicted 
with. This, Dr. Cullen has very improperly placed among his 
eruptive diseases, in the third order, 29 ! merely because of 
the petechias sometimes attendant upon it. He should for the 
same reason place typhus in the same order with plague. 

4. Nor does this order, febres, contain another violent and 



dr. cullen's classification. 35 

dangerous form of fever, dysentery, which holds a very im- 
proper place among his profluvia ! for it is every thing else but 
profluvia. 

(2.) The second order, phlegm asiae, is no less defective. As 
I have already observed, it wants, first, several inflammatory 
diseases, and which indeed are wanting altogether in his 
system of arrangement. It wants otitis, odontitis, mastitis, 
auritis, phlegmasia dolens, periostitis. 

1. In this order Dr. Cullen should also have included many 
diseases which he has elsewhere distributed. This order should 
have contained, first, catarrhus, 39, which is placed in his fifth 
order, profluvia. 

2. Phthisis pulmonalis, embraced under the head of hae- 
moptysis, 36 ! ! 

3. Urethritis — see Locales, order 4, 121 ! 

4. Hydarthrus, 139, Locales, order 6, tumores. 
Phlogosis, the first of his phlegmasia?, might for the same 

reason as a tumour have been here among the Locales. 

(3.) Dr. Cullen's third order, exanthemata, is no less in- 
correct and incomplete. 

1. It is incorrect inasmuch as it contains pestis, 29, which is 
not an eruptive disease any more than any other form of fever. 
And he himself expresses the doubt whether pestis should not 
be placed among the fevers. As I have no doubt on this sub- 
ject, I have placed it among the fevers, in the arrangement I 
have offered for your consideration. 

2. This order is incomplete, as other eruptive ;diseases are 
omitted, and placed among other classes — viz. some in his 
third class, order 3. Impetigines ; and others in his fourth class, 
eighth order, as dialysis and herpes, &c. 

(4.) His hsemorrhagise, order 4, are imperfect — besides the 
error of placing it among the Pyrexiae, this order wants 

1. Haematemesis — 2, haematuria, and 3, hepatirrhcea, a dis- 
charge of blood from the liver as in disease of that organ 
— as occurring, occasionally, in typhus fever, but most fre- 
quently attendant on yellow fever. In the latter disease indeed 
few die without that symptom ; hence the yellow fever is com- 
monly called by the Spaniards, vomito prieto ; but in other fe- 
brile diseases it is only an occasional occurrence, and then fre- 



36 LECTURE II. 

quently is owing to preceding disease of the liver, and that 
too, most generally from intemperance. 

(5.) His order, profluvia, is exceptionable — it has what does 
not belong to it, and wants all that strictly do belong to it. 

It is incorrect as containing two diseases that have no claim 
to this place ; on the contrary, catarrhus is properly one of the 
phlegmasia;, and is constituted by a diminished discharge from 
the membrane, the seat of disease. So with dysentery, its 
companion, in this order ; it should be in the order of febres, 
for it too is constituted by diminished instead of increased dis- 
charges from the intestines. Thus you see that these are any 
thing else but profluvia ! 

This order of profluvia, too, is incomplete, inasmuch as it 
excludes many other diseases of the character here professed, 
as ephidrosis, 117; ephiphora, 118; ptyalismus, 119; cholera, 59; 
diarrhoea, 60; diabetes, 61 ; enuresis, 120; which are distri- 
buted in other parts of his system ; and leucorrhcea, absurdly 
placed, too, among his haemorrhages. 

This order is also incomplete, by excluding altogether some 
other diseases, as otirrhoea, gelactirrhoea, and gonorrhoea — I 
mean strictly so, as its name imports, seminal weakness, from 
yovo?, semen — not urethritis. 

The subdivisions of his second class are no less exception- 
able. 

(1.) Comata, strictly speaking, is a bad order — kojua signifies 
a propensity to sleep. This is not the case with all the palsies, 
for paraplegia, when proceeding from injury of the spine, is not 
always attended with coma. 

The partial palsies should also be here associated — whereas 
they are improperly placed among the Locales, first order ! ! 

(2.) Adynamia^ is incorrect and incomplete — incorrect, as it 
contains a disease of the mind, hypochondriasis, a grade of 
mania, which therefore should be associated with the other dis- 
eases belonging to the vesanise, fourth order. 

It contains, too, chlorosis, 46, which is symptomatic of ame- 
norrhoea, and is no more than a species of dyspepsia. • 

This order, too, is defective, as it separates dyspepsia from 
its congeners. Its opposite diseases are contained in the Locales, 
second order, viz. pyrosis, 57 ; bulimia, 100, &c. 



DR. CULLERS CLASSIFICATION". 37 

It is defective, too, as it excludes altogether, asphyxia, which 
is not contained at all in his system, and anaphrodisia, 108, the 
loss of the venereal appetite and capacity. This is placed 
among the Locales without any regard to the genera] state 
of the system or the general remedies to be presented for its 
relief, for it is sometimes owing to the pressure on the brain by 
plethora. 

(3.) His spasmi are incorrect and defective. 

1. Incorrect, as they contain pertussis, 56, one of the phleg- 
rnasias ; pyrosis, 57, not a spasmodic affection at all, but which 
is properly one of the adynamia^, or rather a symptom of 
dyspepsia ; colica, 58, which embraces many varieties or 
species of enteritis; cholera, 59; diarrhoea, 60; diabetes, 61; 
which are without spasm frequently, and belong to the profluvia. 

2. It contains also dyspnoea, 55 ; a mere symptom, but of 
a great variety of diseases. 

3. It wants a number of diseases, altogether omitted in his 
system ; as tic doloureux, or neuralgia ; tremor ; angina pecto- 
ris.; nephralgia ; hysteralgia ; hepatalgia. 

This order of Dr. Cullen's, notwithstanding these omissions, 
appears to be " a common receptacle for the refuse of the whole 
nosology." This order stands ready to receive every disease 
that happens to be rejected from the other orders. Wilson may 
well ask where is the similarity between hydrophobia and dia- 
betes ? between colic and whooping-cough ? between dyspnoea 
and epilepsy? 

His fourth order, vesanias, wants hypochondriasis, 45, im- 
properly placed among the adynamia?. 

Objections to the subdivisions of his third class — Cachexias. 
His first order, marcores, is somewhat questionable. This signi- 
fies leanness, emaciation — emaciation alone is not sufficient to 
form an order upon, being always symptomatic of other dis- 
eases, as of ulcer, phthisis, abscess, scrofula, poisons. Atro- 
phia, 69, is not a distinct disease, but generally arises from bad 
food, old age, or is symptomatic of dyspepsia, as in dirt-eaters. 

The second order, intumescentias, wants three dropsies, viz. of 
the pericardium, of the ovarium, and of the joints. This order 
also contains an improper genus, rachitis, one of those diseases 
analogous to syphilis, or those arising from a morbid condition 



38 LECTURE II. 

of the system — it is therefore properly one of the vitia, and 
should not be placed here on account of the tumour attending it. 

The third order, the impetigines, is also exceptionable. It 
contains icterus, 90, which arises from a suppression of bile, 
and belongs to a distinct class of suppressiones, not provided 
for by Dr. Cullen. It also contains scrofula, which belongs 
to vitia, denoting the deranged state of the whole system, both 
solids and fluids ; but neither of these should be placed among 
the impetigines or scabby diseases. 

His impetigines, too, are superfluous, as it separates the cuta- 
neous diseases from those in the third order of that class, and 
those of the eighth order of the fourth class. 

Let us now look at his class Locales. 

The first order, if we except caligo, 91, is superfluous — it 
is improper that anosmia should be in the first order, 97, and 
aphonia, in the third, 109. 

The second order of the fourth class is altogether superflu- 
ous — the affections of the stomach, dysorexise, belong mani- 
festly to the same place with dyspepsia, with the adynamise. 

Satyriasis, 103; nymphomania, 104; anaphrodisia, 108, also 
belong to adynamic, i. e. debility of the natural functions. 

Nostalgia, 105, is nearly allied to melancholia, one of the 
vesanise, and is so arranged by Vogel, 65. 

This disease, nostalgia, is a species of melancholy in which 
the predominant symptom is the unceasing and ardent desire to re- 
turn home — of course it only occurs in those who are absent from 
their friends or their native country. It is so called from voo-Tav t 
to return, and *\yos, dolor, pain, or grief — the maladie du pays, 
as the French call it. That Sauvages and Dr. Cullen should 
have given it this place is most extraordinary, as one would 
suppose that there was some particular organ in the body in 
which the amor patriae resides, as hunger and thirst in the sto- 
mach. This disease is not confined to the Swiss, but in a pe- 
culiar manner affects the Swiss and the unhappy African, as 
well as the people of other countries, torn from their native 
land and the society of their friends and connexions. 

3. The third order are all neuroses, all palsies, excepting 
contractura, which is symptomatic of wounds or other inju- 
ries, or should be placed among the deformitates. 



DR. CULLEN'S CLASSIFICATION. 



4. The fourth order are all profluvia, not Locales, viz. ephi- 
drosis. 

5. The fifth order, are all general diseases, not local. They 
belong strictly to suppressiones or obstructions. 

6. The sixth order, tumores, is incorrect, containing bubo, 
132, which is generally symptomatic — hydarthrus, 139, of the 
phlegmasia^. It is also imperfect ; it wants bronchocele, fungus 
hasmatodes, polypus. 

7. The ectopias are unexceptionable. 

8. Dialyses. Ulcer and caries are synonymous, as caries 
is an ulcer of the bone. This order is also faulty, contain- 
ing cutanei — and especially as these are not all local. Besides, 
it involves a gross absurdity to bring together diseases so per- 
fectly incongruous as some of those embraced in this class ; 
for what possible connexion or affinity, I ask, can be found be- 
tween psora, the itch, and a broken bone ? They stand next 
to each other as you perceive in Dr. Cullen's arrangement. 

I shall now proceed to make a few remarks relative to the 
arrangement here adopted, and which I propose to observe in 
the prosecution of this course of lectures. 

Adverting to the s}moptical view which is prefixed to the 
plan proposed, you will perceive, in the first place, I have re- 
jected the class Pyrexias altogether, as too general. 

It is difficult, upon many occasions, to make precise distinctions 
between diseases that are febrile and those without pyrexia. 
Many diseases are febrile upon some occasions, but not so on 
others. Many local diseases become febrile by the severity of 
pain or the continuance of the irritation, or by derangement of 
particular organs. Any cause that gives a great shock to the 
constitution is capable of producing general pyrexia, and vice 
versa. As local complaints often produce pyrexia, so on the 
other hand, pyrexia predisposes to, and produces local com- 
plaints — hence local complaints in typhus fever or abscesses. 
Pneumonia and rheumatism are oftentimes the produce of 
general inflammatory fever ; and the disease changes its name. 
Dysentery and diarrhoea frequently produce fever, and fever, in 
some cases, produces those diseases. 

I have therefore unhesitatingly rejected Pyrexias, as a class, 
as being too general, for indeed, for the reasons I have assigned, 



40 LECTURE II. 

it might have embraced almost every disease of the human 
body. 

I have therefore commenced my classification with fevers, 
strictly so called ; that is, those diseases which are more espe- 
cially so denominated by writers, and are acknowledged to be 
such by the profession, and by mankind in general. 

I now propose to you the following classification, as one 
which, though still very imperfect, I really think more conform- 
able to nature than any yet proposed ; and more than any other, 
subservient to the great purposes of practice — and this shall be 
the order in which the diseases of which I shall treat, will be 
considered. 

SYNOPTICAL VIEW OF THE SYSTEM PROPOSED 
BY DAVID HOSACK. 

CLASS L— FEBRES. 

Ord. I. Intermittentes. 

1. Quotidiana. 3. Quartana. 

2. Tertiana. 

Ord. II. Remittentes. 

4. Remittens biliosa. 5. Remittens infantilis. 

Ord. III. Continues. 

6. Synocha. 9. Pestis orientalis. 

7. Typhus vel Synochus. 10. Pestis tropicus. 

8. Dysenteria. 

CLASS II.— PHLEGMASIA. 

11. Phlogosis. 25. Carditis. 

12. Phrenitis. 26. Phthisis. 

13. Ophthalmia. 27. Glossitis. 
,14. Otitis. 28. Tonsillitis. 

15. Odontitis. 29. Pharyngitis. 

16. Parotitis. 30. (Esophagitis. 

17. Mastitis. 31. Peritonitis. 

18. Catarrhus. 32. Gastritis. 

19. Laryngitis. 33. Enteritis. 

20. Trachitis. 34. Hepatitis. 

21. Bronchitis. 35. Splenitis. 

22. Pertussis. 36. Pancreatitis. 

23. Pneumonia. 37. Nephritis. 

24. Diaphragmitis. 38. Hysteritis. 



dr. hosack's classification. 



41 



39. Cystitis. 


43. Cruritis. 


40. Urethritis. 


44. Rheumatismus. 


41. Orchitis. 


45. Arthritis. 


42. Proctitis. 


46. Paronychia. 




CLASS III.— CUTANEI * 




Ord. I. Papula. 


47. Strofulus. 


49. Prurigo. 


48. Lichen. 






Ord. II. Squamje. 


50. Lepra. 


52. Pityriasis. 


51. Psoriasis. 


53. Ichthyosis. 




Ord. III. Exanthemata. 


54. Rubeola. 


57. Roseola. 


55. Scarlatina. 


58. Purpura. 


56. Urticaria. 


59. Erythema. 




Ord. IV. Bullc 


60. Erysipelas. 


62. Pompholyx. 


61. Pemphigus. 






Ord. V. Pustule. 


63. Impetigo. 


66. Variola. 


64. Porrigo. 


67. Scabies. 


65. Ecthyma. 






Ord. VI. VEsicuLiE. 


€8. Varicella. 


72. Miliaria. 


69. Vaccinia. 


73. Eczema. 


70. Herpes. 


74. Apthse. 


71. Rupia. 






Ord. VII. Tubercula. 


75. Phyma. 


80. Sycosis. 


76. Verruca. 


81. Lupus. 


77. Molluscum. 


82. Elephantiasis. 


78. Vitiligo. 


83. Framboesia. 


79. Acne. 






Ord. VIII. Macule. 


84. Ephelis. 


85. Nsevus, Spilus, &c 




CLASS IV.— PROFLUVIA. 




Ord. I. Hemorrhagic. 


86. Epistaxis. 


90. Haematuria. 


87. Haemoptysis. 


91. Menorrhagia. 



88. 
89. 



Hsematemesis. 
Hepatirrhoea. 



92. Haemorrhois. 



* This class is formed upon the admirable arrangement of diseases of the 
skin, proposed by Dr. Willan, and improved by Dr, Bateman, 
5 



42 



LECTURE II. 



93. Ephidrosis. 

94. Epiphora. 

95. Otirrhoea. 

96. Ptyalismus. 

97. Galactirrhoea. 

98. Cholera. 



Ord. II. Apocenoses. 

99. Diarrhoea, 

100. Diabetes. 

101. Enuresis. 

102. Leucorrhoea. 

103. Blenorrhoea. 

104. Gonorrhoea. 



CLASS V.— SUPPRESSIONES. 

105. Icterus. 109. Dyspermatismus. 

106. Obstipatio. 110. Amenorrhoea. 

107. Ischuria. 111. Dyslochia. 

108. Dysuria. 112. Agalactia. 



CLASS VI.— NEUROSES. 
Ord. I. Dysesthesia. 



113. Asphyxia. 

114. Apoplexia. 

115. Paralysis. 

116. Amaurosis. 

117. Caligo. 

118. Dysopia. 

119. Pseudoblepsis. 

120. Strabismus. 



121. Paracusis. 

122. Anosmia. 

123. Agheustia. 

124. Paraphonia. 

125. Psellismus. 

126. Dysphagia. 

127. Anaesthesia. 



Ord. II. Adynamia. 



128. Syncope. 

129. Dyspepsia. 

130. Satyriasis. 



133. Tetanus. 

134. Neuralgia. 

135. Convulsio. 

136. Chorea. 



140. Sternalgia. 

141. Pleuralgia. 



131. Nymphomania. 

132. Anaphrodisia. 

Ord. III. Spasmi. 

a. In functionibus animalibus. 

137. Epilepsia. 

138. Catalepsia. 

139. Cephalalgia. 

b. In functionibus vitalibus. 
142. Asthma. 



c. In functionibus naturalibus, 



143. Colica. 

144. Nephralgia. 

145. Hysteralgia, 



146. Hysteria. 

147. Hydrophobia. 



DR. hosack's classification. 



43 



148. Amentia. 

149. Oneirodynia. 



152. Marasmus. 

153. Plethora. 

154. Polysarcia. 

155. Emphysema. 

156. Tympanites. 



158. Hydrops cellularis. 

159. Hydrops cerebri. 

160. Hydrops spinas. 

161. Hydrops thoracis. 

162. Hydrops abdominis. 



167. Physconia. 

168. Rachitis. 

169. Fragilitas ossium. 

170. Moilities ossium. 

171. Lithiasis. 



Ord. IV. Vesani.se. 

150. Melancholia. 

151. Mania. 

CLASS VII.— CACHEXIA. 
Ord. I. Marcores. 

Ord. II. Intumescenti^. 

a. Sanguinece. 

b. AdiposcB. 

c Flatuosce. 

157. Physometra. 

d. Aquosce. 

163. Hydrops uteri. 

164. Hydrops ovarii. 

165. Hydrops testis. 

166. Hydrops articuli. 

e. Solidce. 



Ord. III. Vitia. 

172. Scrofula. 

173. Syphilis. 

174. Scorbutus. 

175. Plica. 



CLASS VIII.— LOCALES. 

Ord. I. Tumores. 

a. Hcematici, 

176. Fungus hsematodes. 

177. Aneurisma. 

178. Varix. 



181. Scirrhus. 

183. Polypus. 

184. Ganglion. 

186. Sarcoma. 



179. Ecchymoma. 

180. Hematocele. 



b. Adenosi. 

182. Carcinoma. 

c. Gelatinosi. 

185. Hydatis. 

d. Adiposi. 

187. Encystis. 



44 



188. Exostosis. 



189. Hernia. 

190. Prolapsus. 

192. Vulnus. 

193. Laceratio. 



196. Enthesis. 

197. Venenatio. 



LECTURE II* 

e. Osteosi. 
Ord. II. Ectopia. 

191. Luxatio. 

Ord. III. Dialyses. 

194. Fractura. 

195. Ulcus. 

Ord. IV. Tychica. 

198. Verminatio. 
Ord. V. Deformitates. 



We are now prepared to enter at once upon the description, 
causes, and cure of diseases. To-morrow, then, we shall be- 
gin with fevers. 

" To-morrow," in the language of the shepherd swain, Ly- 
cidas, 



" Te-morrow to fresh fields and pastures new.' 



45 



LECTURE III. 



OF FEVERS IN GENERAL. 



The term fever, or febris in Latin, has been variously 
derived. Some derive it from ferveo, to burn, or fervor, heat. 
Others derive it from februo, a verb signifying to depurate or 
purify — believing fever to be an effort of the system, by which 
it throws off any impurities which may be received or engen- 
dered in the body. The Greeks denominated it irugei-is, and 
wyga/ro?, from w^ fire. 

Fever is one of the most common, and one of the most 
dangerous affections of the human frame. It is common to 
both sexes. All ages are subject to it. It is found in all coun- 
tries and in all climates. None are exempt. Sydenham sup- 
posed fever, strictly so called, to constitute two-thirds of the 
diseases which prove fatal to the human species ; and he has 
calculated that eight out of nine of all who die, are cut off by 
febrile diseases. This computation is too high, considering 
fever in the limited sense in which we employ it. But, consi- 
dering it as comprehending every affection in which the febrile 
state exists, it certainly makes up a very large proportion of 
the diseases fatal to mankind. Indeed, fever is so universal a 
disease, that it may be said few either live or die without it. 
Few go out of the world or remain in it without fever. 

By Hesiod, fevers are hence denominated by the general 
term, " disease." And Horace in emptying Pandora's box, 
calls all diseases, " fevers." 

" Post ignem setherea domo 
Subductum macies, et nova febrium, 
Terris incubuit cohors." 
5* 



46 LECTURE III. 

Its importance, therefore, to the physician, and consequently 
to the student, becomes very apparent, especially when we 
view it as one of the great outlets to human life. Indeed, a 
physician is or is not entitled to that distinguished appellation ; 
he is or is not skilful, successful, or eminent, in proportion as 
he is or is not acquainted with this important class of diseases. 
And as he is well instructed in the nature and treatment of 
fevers, he will be successful in the treatment of diseases in 
general, as all diseases occasionally assume a febrile character. 
Hence Dr. Gregory used to devote the greater part of the six 
months' session to this subject, and the phlegmasia? ; for he very 
rarely reached the second class of diseases in the arrangement 
of Dr. Cullen, which, with all its defects and errors, is adopted 
in the university of Edinburgh ! 

What is fever ? It is difficult to answer this question. It 
has become almost a proverb, that the wisest man knows not 
the nature of a fever. Notwithstanding the long experience of 
mankind on this subject, and the investigation which has been 
bestowed upon it by physicians, much yet remains to be 
done in the investigation of this intricate subject. The only 
safe mode of procedure in arriving at a knowledge of this 
condition of body, will be carefully to note the facts which 
have presented themselves on this subject : for as that great 
practical observer, Sydenham, justly observes, " If we se- 
riously attend to what nature actually performs, and observe 
what instruments she uses in her work, we may be able to dis- 
cover her operations ; but," he adds, " the manner in which 
she operates, if I am not mistaken, will always be concealed." 

It is therefore proposed first to notice the symptoms of 
fever. 

Symptom is a Greek word, derived from the verb <rvvm7rra>, 
to happen — to occur. It signifies thence, an appearance or 
occurrence. It is a term, moreover, appropriated to disease, 
but not to health. We say phenomena of health, but we say 
symptoms of disease. Another term made use of as adjective 
to symptom, is pathognomonic, derived from tt^oc, an affec- 
tion, and yivocnto, to know ; meaning thereby those peculiar 
symptoms by which the affection or disease may be known, to 
distinguish it from all others. Diagnostic is another adjective, 
frequently made use of by the physician, as expressing the 



OF FEVERS IN GENERAL. 47 

quality of symptoms, and signifies those symptoms by which 
any two or more diseases may be distinguished from one an- 
other — i. e. by which two or more diseases, having a close 
resemblance, may be separated from each other — as plague 
and yellow fever. 

The term pyrexia, made use of by Dr. Cullen, (the febris 
of authors) was first introduced as synonymous with fever, by 
Sauvages. But Dr. Cullen first used it as the name of a class. 
Read Cullen's definition of the pyrexiae, " post horrorem pulsus 
frequens, calor major, plures functiones lsesge, viribus presertim 
artuum hnminutis." 

Of the post horrorem, Dr. Cullen was very tenacious in his 
description of fever. Not one, says he, of a thousand occurs 
without it. 

Boerhaave also considers chilliness essential in all fevers 
arising from internal causes. By internal cause, he meant 
that which existed in the body, before the fever appeared ; and 
that whether generated within the body, or introduced into it 
from without. The bile vitiated, is an example of the first ; 
the pestilential contagion of small-pox, of the last. Yet both 
exist in the system before the fever makes its appearance ; and, 
therefore, are considered as internal causes. But shivering, 
Boerhaave observes, is not present when fever proceeds from 
external causes, as sudden anger — violent and long-continued 
exercise. Then " no coldness, (he remarks,) is perceived to 
precede fever." Nor is it true of cases arising from internal 
causes that the chill is always present. It is an objection 
then to Dr. Cullen's definition of pyrexia, that some fevers 
are not preceded by chill or shivering. This fact was noticed 
as early as the time of Celsus. " xilice protinus a calore 
incipiunt." De Med. lib. 3. cap. 3. The same has been ob- 
served by many moderns : as Gorter, Compend. Med. Tract. 
52. § 3. Burserius Inst. Med. Pract. vol. 1. p. 83 ; by For- 
dyce, Diss, on Simp. Fever, p. 11; and by Dr. Gregory, who 
remarks, that in the common quotidian there is frequently no 
cold stage. 

Cases of yellow fever too have frequently occurred, in which 
the patients w T ere very suddenly seized w T ith all the violence 
characteristic of that disease, without the least preceding sense 



48 LECTURE III. 

of coldness. So in plague also ; even in intermittents, I have 
observed the same fact. 

Hence, probably, has arisen the supposed distinction which 
is made by the vulgar between the intermittent and the fever 
and ague. 

In other respects, Dr. Cullen's definition of pyrexiae contains 
for the most part a correct character of fever, except that 
" viribus artuum imminutis," is not properly applicable as 
mere debility, but as the effect of irritation, depriving the pa- 
tient of an inclination for exertion and begetting a sense of 
lassitude. But Dr. Cullen doubtless intended to convey the 
idea of pure debility; for by this supposed debility, he intended 
to strengthen his favourite hypothesis of debility's constituting 
the proximate cause of fever. 

But when we come to look at his definition of fever, strictly 
so called, we shall find it exceptionable throughout — " prse- 
gressis languore, lassitudine et aliis debilitatis signis, pyrexia 
sine morbo locali." I assert, there is not one word of truth in 
this whole definition. On the contrary, the invasion of fever 
is frequently sudden, without any previous languor or] lassitude, 
without any precursor or premonitory feelings whatever, and 
most commonly, or at least very often, without any debility, 
previous to the symptoms of increased action. And sometimes 
fever is attended with local affections from the commencement 
■ — as of the brain, showing itself in violent pain of the head, 
delirium, and even mania. Indeed, Clutterbuck would have 
you believe, that all fevers arise from and consist in an inflam- 
mation of the brain. Dr. Parr considers a tension of the ten- 
dons of the wrist to be a constant symptom of fever. Dr. 
Fordyce also considers some mental alienation to be present in 
every fever. 

Such local affection shows itself also in the lungs in cough- 
ing, as in typhus. The throat too, in the commencement of 
typhus, is frequently sore and even inflamed, owing to the state 
of the stomach. 

The stomach too is frequently affected from the beginning 
with vomiting, as in yellow fever ; and that too, in some cases 
is irrestrainable — such is the sensibility of that viscus to the 
operation of the poison of that disease. 

And in plague the glands of the groin and axilla are some- 



Or FEVERS IN GENERAL. 49 

times among the first seats of irritation. It is accordingly re- 
marked by almost all writers, that in proportion as those local 
affections appear early in the plague, the disease of the whole 
system becomes mild. Dr. Russel observes, that some cases 
of plague he prescribed for from his window — the patient 
having nothing but local affections or buboes. This, there- 
fore, is a bad definition given of fever by Dr. Cullen. 

Galen considered fever a preternatural heat generated in 
the heart, and from thence diffused throughout the body. 

It is true, that the greatest source of heat is in the neighbour- 
hood of the heart, viz. in the lungs, the fire-place where, by 
the constant condensation of the oxygen, the caloric which 
gave the oxygen its gaseous state is disengaged. It is now, 
however, considered that the lungs are not the only source of 
the heat of the system ; but that the various processes of di- 
gestion, chylification and assimilation, indeed, that all the de- 
compositions and new combinations in our system, are attended 
with an extrication of caloric, besides that arising from the 
process of respiration. 

Sennertus and Vogel following the ancients, Galen and 
others, made increased heat alone the essence or proximate 
cause of fever. There is great error in this respect. In the 
first place, the feelings of a physician mislead him, for the 
sense of feeling like all the other senses is frequently falla- 
cious. The sense of heat must necessarily too be relative, accord- 
ing to the temperature of our own bodies, or that temperature 
to which we had been previously exposed, or have just come 
from : and before the time of Van Helmont (who was born 
1577, and died 1644,) we had no measure of heat by the glass 
and mercury. Indeed, this measure was only made use of 
within the last hundred years. 

Van Helmont first invented a measure of heat by the ex- 
pansion of air in a glass globe, pushing up when heated a fluid 
through a small cylinder, and allowing, when cold, the fluid to 
descend. By this instrument, as it was afterwards improved, 
we now measure the apparent heat of bodies. But besides the 
fallacy of our feelings, in some instances the heat of the pa- 
tient is not increased, it is even lessened, as in the first stage of 
fever ; yet the pulse is, perhaps, increased in frequency. Dr. 



50 LECTURE III. 

Cullen admits this to be the case, as you will find by consulting 
his notes. His notes he finds very convenient to relieve him- 
self from the difficulties in which he becomes involved in his 
text — " neque calor major, &c. to negere nolo." See Noso- 
logia, p. 43. 

Heat being the result of quickened circulation and quickened 
respiration, must necessarily be absent in the first stage of 
most fevers, as it requires time to produce that effect, and 
therefore it is not to be looked for as a pathognomonic or es- 
sential characteristic symptom of fever : on the contrary, in 
some cases it is even reduced below the natural temperature. 
Fordyce found it less in fever by actual measurement, and yet 
all other appearances denoting fever were present. He 
found it at 96°, 95°, and even at 94°; and that too under 
the tongue, (the natural temperature of the body in health 
is 98, or rather 97J under the tongue.) Dr. Currie states, 
that he has found the heat under the tongue and in the 
axilla as low as 94°, 93°, and even down to 92°, (see Med. 
Reports on cold and warm water in fevers, 2d ed. p. 168,) 
and in other cases Dr. Fordyce remarks, that the patient 
feeling cold, his heat was up to 104° and 105° — indeed 110° 
and 112°, are mentioned by authors. The experiments of 
Dr. Fordyce frequently show no increase of cold, though it 
is felt and complained of by the patient. But the heat of the 
body is also very variable, and that too frequently in a few 
minutes, depending on accidental circumstances. It will de- 
pend somewhat upon the temperament of body, upon the con- 
dition of the nervous system, as well as the circulation. Hence 
the heat of some persons is greater than that of others. I 
have oftentimes met with this extraordinary degree of heat in 
persons of the nervous temperament, in which a great quantity 
of blood circulates upon the more sensible parts of the body. 
This is the case with myself. 

In very fat persons the temperature of the surface of the 
body is deceiving — for the skin in very fat persons is to a 
degree insulated and relatively cold, from the mass of fat be- 
neath, which is a non-conducting medium ; as is the case in 
some children as well as adults. The elder Dr. Bard was 
hence in the habit, when prescribing for children, of feeling the 
forehead, not trusting to the extremities to ascertain the heat 



OP FEVERS IN GENERAL. 51 

of the body — for where the limbs are disproportionately large, 
they are generally cool. 

In ascertaining the temperature of the body, you will there- 
fore recollect, that feeling the limb is not a test of the degree 
of caloric present. To obviate this difficulty, the thermome- 
ter must be applied to some other part of the body for this 
purpose. Dr. Currie had a curved thermometer purposely con- 
structed, that it may be introduced into the mouth, or in the 
axilla, or any other part of the body that possesses a pretty 
uniform degree of heat. 

Heat, therefore, is not a pathognomonic symptom of fever. 

Heat too is frequently partial in its operation, as in typhus 
fever ; and frequently in convalescence shows itself in the 
more sensible parts of the body, as in the temples — the cheeks 
—palms of the hands — soles of the feet — and yet there is no 
fever present. Celsus, therefore, may with great propriety 
say of heat as of the other supposed characteristics, that it is 
" asque fallax." 

Sylvius and Boerhaave were no less in error, in making the 
velocity of the pulse one of the essential characters of fever. 

The pulse has in all ages been referred to, as an evidence of 
fever. 

The pulse, before the time of Celsus, was not much no- 
ticed. 

Galen says, that Hippocrates was the first who mentioned 
the pulse — he however did not place great dependence upon 
it. Hippocrates certainly examined the pulse, and judged 
of the violence, of fever by it : — thus, he says, the pulsa- 
tions in lethargic patients are slow — that he found the pulsa- 
tions slow and trembling in Zoilus the workman. In the case 
of Polycrates too, he observes that the fever was so gentle, 
that the pulse seemed to stand still, except in the temples. And 
again, he remarks, that in the most acute diseases, the pulsa- 
tions are the largest and hardest. — (See his Prognostics.) 

The pulse was more noticed afterwards by Herophilus and 
Erasistratus, and particularly by Aretaeus. But in the time of 
Celsus, it became an object of considerable attention. Yet 
Celsus, speaking of it as a criterion of fever, has well called 
it, " fallacissima res." 

" In every fever," says Boerhaave, (I mean Herman, the 



52 LECTURE III* 

sun of the medical world,) " arising from internal causes, there 
is always a shivering, a quick pulse, and heat varying in de- 
gree at different times of the fever." This observation is cer- 
tainly incorrect, for though great heat may be present, the pulse 
sometimes is in fever not quicker than natural. Nay, in some 
cases it is slower, for we may observe that quickness of the cir- 
culation and the degree of heat are not invariably proportioned 
one to the other, although they are generally so. The ge- 
neral standard of the pulse we know to be about seventy-three, 
with men of active habits; and while actively engaged, it is 
somewhat quicker. In truth, we may say it is rarely less 
than seventy, nor more than seventy-five. It is not so more 
than once in a thousand cases, excepting in old age, or when 
the constitution may possess some peculiarities or idio- 
syncrasies, as in the charter-house man, noticed by For- 
dyce, whose pulse did not exceed twenty-six. I have also 
had a patient in this city, whose pulse did not exceed forty- 
five, though he enjoyed good health. He died in his 80th 
year. In early and active life it never exceeded sixty, 
and even during fever it was not very perceptibly quickened, 
yet every other symptom of fever was present. In infancy the 
pulse is more frequent than in the adult, oftentimes exceeding 
a hundred in a minute, and that too in health. 

Dr. Gregory related to us a case in which the pulse during 
fever was always diminished instead of being increased in 
frequency. In that case the constriction attendant on fever, 
it appears, was not confined to the smaller vessels, but extend- 
ed to the heart and larger vessels also. The subject had been 
a patient of his father and himself.* 

Sydenham has observed of a malignant fever (febris hye- 
malis,) that during the first days, the pulse was that of health. 
" Sanorum pulsui non admodum absimilis." — Tractat. de hy- 
drope postcripto. 7 

I have oftentimes seen the same in yellow fever, and that 



* My original note taken in 1792. Pulse.— Instance of a man by Dr. Gregory, 
whose pulse in health is 120 — also of one whose pulse naturally did not exceed 
50, and when at 70 or 72, the natural standard, he was dangerously ill. Of a 
man also, whose pulse in health was quick and irregular, viz. 120 per minute, 
but in fever, became both slower and regular. 



OF FEVERS IN GENERAL. 53 

too throughout the whole course of the disease. The same 
fact has been observed in small-pox. 

Greding has observed the same in a contagious epidemic 
fever, as you will see in Ludwig Adversar. Med. vol. I. pt. 1. 
cap. 1. p. 22. 

That the pulse is slower than natural, has frequently been 
observed in malignant fevers, especially those proceeding from 
contagion. In typhus fever the pulse is frequently observed to be 
less than the natural standard, down sometimes to sixty, fifty, 
forty-five, and even to thirty, while other symptoms of fever 
are present. Even in inflammatory complaints, the pulse in 
some cases is very small and difficult to be perceived. 

Similar facts are stated by Burserius, p. 84 , by Russel, in 
his Diseases of Aleppo, p. 230 ; by Sauvages, torn. 2. p. 307. 
De Haen in his Rat. Medend. pt. 12. cap. 2. p. 50 et 117. 

The last mentioned author observed, that in a particular 
case, as in Dr. Gregory's clergyman, it was not only slower 
during the continuance of the fever, but became quicker during 
convalescence and health ; nothing is more common than the 
quick pulse and a corresponding degree of heat in convales- 
cence, though the patient is free from fever. 

Home also states 5 that he has lost patients of typhus fever, 
in whom the pulse was not quickened. The depressing or se- 
dative effects of the contagion producing typhus, is not unfre- 
quently exhibited in this manner on the arterial system. — (See 
also Pringle, Lind, and Fordyce, for similar facts.) 

The latter, in St. Thomas's hospital, frequently called his 
pupils' attention to this irregularity of the pulse — this almost 
capriciousness as it might be denominated, in malignant fevers. 

In diseases too of no danger, the pulse is sometimes very 
inordinately accelerated. In a common catarrh, it is often as 
high as 120; in cynanche tonsillaris, 130 or 140 or 150 ; but 
the same frequency in continued fever is generally attended 
with great danger. 

Again, we frequently find no fever, even when the pulse is 
quickened beyond the natural standard — because it is much 
influenced by the state of the nervous system. 

Let me tell you the case of Mr. Boyd, a pupil of mine, who 
was ill of the yellow fever in 1795. I did not feel very confi- 
dent as to his safetv, and called Dr. Bard to visit him. The 



54 LECTURE III. 

Doctor, upon feeling his pulse, without giving much attention 
to his other functions, instantly turned on his heel, and walked 
out. " Hosack," said he, " this man will die." " I hope not. 
sir." " Did you feel his pulse ?" he added. — I returned to 
make a more particular inquiry as to his situation, and found 
his pulse quite as tranquil as I had done before Dr. Bard's visit. 
I also found he had been out of bed on his chair, and hearing 
us coming to his room, hurried to his bed, which excited his 
circulation at the moment. In that moment of agitation, Dr. 
Bard felt his pulse — he recovered. Getting out of bed in ordi- 
nary cases, or any other bodily exertion in this irritable state 
of the system, accelerates the circulation. 

The same thing occurs during the exercise of walking, run- 
ning, dancing, or even the exercise of gestation, as riding on 
horseback, or in a carriage. Yet, with this temporary acce- 
leration of the heart or vessels, no fever is produced. 

In like manner in spasmodic affections, as of the intestines, 
the pulse is sometimes quickened to a hundred, yet no fever 
exists. In palpitation of the heart also, the pulse is very rapid, 
but it does not constitute fever. 

The pulse is no less affected by the passions of the mind, 
than it is by other impressions made upon the nervous system, 
or the peculiar irritation, which is the cause of the disease. 
When the fair one meets her intended, her heart may be lite- 
rally said to leap with joy. But her arteries are also excited 
and her pulse is quickened, not by their own vis insita, but by 
impressions made through the medium of the mind upon her 
nervous system. 

There was a case during my attendance in the Pennsylvania 
Hospital, in 1789 : a poor man was ill of dropsy — bed-ridden 
and debilitated, of course irritable and alive to every impres- 
sion. The approach of the physician and a retinue of pupils, as 
you will suppose, (for they did not observe that decorum in the 
wards of the sick, that they do at this day,) agitated him — his 
pulse was greatly excited, and in that increased action vene- 
section was prescribed by Dr. Rush — the poor man died within 
four hours after the operation. 

It is a good rule, therefore, not to feel the pulse of your pa- 
tient immediately upon your entrance into the sick room ; for 
the very opening or shutting of the door, the appearance of 



OF FEVERS IN GENERAL. 55 

a new object before your patient, excites the heart and vessels 
to more frequent action, which may deceive you. 

Celsus, speaking of the effects of fear, anger, and the other 
passions and emotions of the mind — the effects of heat and 
exercise, &c, on the pulse, has well observed, " Quam facile 
mille res turbant;" " how easily is it affected by a thousand 
things." 

Neither the pulse, nor the temperature then can be considered 
as pathognomonic symptoms of fever ; nor consequently, respi- 
ration ; for it, like the pulse, is much influenced by the state of 
the nervous system, as well as the circulation. 

Boerhaave used to tell his pupils, that he had been at great 
labour to assemble from different authors, the symptoms of 
fever ; and that from this catalogue he blotted out all those 
symptoms which he did not find to be present in all fevers. 
He found of all the catalogue he had collected, but three re- 
mained — shivering, a quick pulse, and heat. But upon the 
same principle, he might have blotted them all out, for no 
one, as we have seen, is invariably present : no one is to be 
considered as a characteristic or pathognomonic evidence of 
fever. 

I have thus endeavoured to show you, what fever is not. 

Dr. Rush has well observed, that before we can arrive at 
truth upon any subject, we must first exhaust it of all its 
errors. Some of these we have endeavoured to clear away 
as preparatory to a more distinct view of this important sub- 
ject. In our next we shall show you, that in every fever there 
is a concourse of many symptoms, in some more, in others 
less. 



56 



LECTURE IV 



THE SYMPTOMS OF FEVERS IN GENERAL. 



Agreeably to the plan announced to you yesterday, it is 
now proposed to call your attention to the concourse of 
various symptoms which enter into, or constitute fever. And 
in doing so, we shall detail the various symptoms in the order 
in which they usually take place, noticing not only those ap- 
pertaining to a particular species of fever, but those which 
belong to fever in general, under whatever shape or form it 
may appear; whether intermitting — remitting, or continued, 
reserving the peculiar symptoms of each specific form for 
future and distinct consideration. 

This plan has an advantage as subservient to practice. 
For after the general view we propose to take, we shall be 
prepared for every deviation or change which may occur in 
any particular species. We shall not only readily know the 
various grades of malignancy which may occur, but we shall 
also be prepared to apply the general principles of treatment, 
and to adapt that treatment to each particular case that may 
present itself, and to the various grades and modifications 
which may occur even in the same case. 

Cullen, Fordyce, and others, take as their standard the pa- 
roxysm of an intermittent ! This is certainly incorrect, to 
make the peculiar form of an intermittent the standard for all! 
An intermittent for a continued fever ! 

Dr. Cullen doubtless found it very favourable to his peculiar 
views relative to the nature and proximate cause of fever, in 
which unfortunately he has been blindly followed by others. I say 
blindly followed, for there is certainly not that affinity between 



SYMPTOMS OF FEVERS IN GENERAL. 57 

the intermittent and continued form of fever that writers have 
imagined — nor that unity which our countryman, Dr. Rush, 
supposed: the one, therefore, cannot stand as the prototype of 
the others. The paroxysms of the one are not found in the 
others, as they have been represented. Many believe that 
every continued fever consists of the paroxysms of an inter- 
mittent running into each other ; that all fevers are originally 
intermittents — to use a chemical expression, that they all have 
an intermittent base. This idea is too absurd to call for a se- 
rious refutation, although it is the error of two of the most 
celebrated practical physicians. 

The whole of the symptoms which occur in fever in all its 
various forms, will now be presented to you, as preferable to 
the partial view which each specific fever exhibits. Know- 
ing the whole, we shall afterwards readily recognise the 
parts which compose it. Much labour too will be saved, in- 
asmuch as after the general description now to be given, we 
shall in describing particular fevers, more especially confine 
ourselves to their characteristic symptoms, omitting altogether 
those they possess in common. 

Fever I define to be, an affection of the whole system. 

Some affect to say, that this definition is too extensive — they 
ask, how is it possible that fever can affect the whole system ? 
What effect can fever have upon the bones 1 upon the carti- 
lages or the ligaments 1 But when Hippocrates in his seventh 
aphorism states, that a wound penetrating into the cavity of 
a bone, may produce a delirium, we find no difficulty in ad- 
mitting the connexion between the bones and the brain — why, 
therefore, should not a similar connexion exist when the brain 
or blood-vessels are primarily affected'? And do we not 
oftentimes find the bones affected with disease as the conse- 
quence of fevers'? viz. rheumatism, white-swelling, necrosis, &c. 

My definition, that fever is " a disturbance of all the func- 
tions," is adopted by Dr. Wright — (see Med. Chir. Journal, 
new series, p. 311. vol. 1.) lately too by Prof. Jackson of 
Boston, and by Dr. Potter of Baltimore ; and, indeed, the same 
is now adopted substantially in the Philadelphia school. 

We shall now proceed to show you, that fever is a disease 
of the whole system — a disturbance of all the functions ; that it 
6* 



58 LECTURE IV. 

appears no less in the faculties of the mind, than in the func- 
tions of the bodily structure — that it shows itself in every organ 
of our frame, and affects every nerve and fibre of the system. 
That the absorbing, the circulating, and the secerning systems 
of vessels are all affected by it ; that it shows itself in the fluids 
as well as the solids. In a word, that it is omnipresent — that 
it has no one pathognomonic symptom, but is constituted by a 
concourse of symptoms. 

Yet it is to be understood, that all the symptoms which are 
met with in fever, are not combined m every case. In this 
respect, there is an endless variety. As for example — the 
state of the tongue, which is generally considered by phy- 
sicians as an index of the presence and state of fever, yet 
a very fallacious one. In inflammatory fever it is for the 
most part white, furred, and dry ; but in plague and in 
yellow fever, and other contagious fevers, it is frequently 
moist and clean throughout the whole course of the dis- 
ease. In the bilious remitting fever, as it ordinarily ap- 
pears in this country, the tongue is uniformly foul and loaded, 
not with a white fur, but with a yellow sordes ; and in typhus 
fever it is dry, red, brown, and black. So with regard to 
headach, this is sometimes present, at other times absent ; and 
so with pain in the back, loins, and limbs, chill, affections of the 
stomach, — in some persons, one of these symptoms occurs — 
in others another, and in a third, a different symptom. 

We may, indeed, observe of fever, that there is no one 
symptom but is occasionally absent, and no one but is occa- 
sionally present. Nor in fever are all the parts of the system 
equally or uniformly affected. Sometimes one part, sometimes 
another is more affected ; depending upon temperament, season 
of the year, climate, and a thousand other circumstances. 

Fevers differ in their duration and violence, as well as in 
their character, from the ephemera or fever of a day (occasion- 
ed by a feast or a debauch,) to a six weeks' typhus fever, or 
the long nervous fever, as it was formerly denominated. 

Seeing then that there is no one symptom or circumstance 
to characterise fever — neither chill, nor pulse, nor heat, nor 
state of the respiration — Dr. Cullen has added to his " calor 
major," and " pulsus frequens," the " functiones lsesse," — the 
deranged or disturbed state of the functions with which he 



SYMPTOMS OF FEVERS IN GENERAL. 59 

should have begun, instead of the " progressis languore." But, 
as I have already intimated, he had his peculiar reasons for 
it — he had a theory, a peculiar doctrine to support, or rather 
the baseless fabric of a vision. Let us respect the memory of 
Dr. Cullen ; but let us respect truth more. " Amicus Plato sed 
majus arnica Veritas," is our motto. The services of Dr. Cullen 
to his profession have been great, they are invaluable. They, 
however, chiefly appear in his description of diseases : this 
is the best part of his works. But although much of that was 
taken from Hoffmann, and from Sydenham, and without the 
due acknowledgment of the sources from whence he derived 
such details, yet he himself also collected much from the 
book of nature at the bedside. And it is to be remarked, and 
to the honour of Dr. Cullen, that he never suffered his own 
hypothesis to accompany him to the bedside. His treatment 
of diseases was ever the result of his cautious and judicious 
experience and observation. Like Galen of old, he had too 
much good sense to be governed even by his own peculiar 
doctrines. 

In proceeding to give a description of fever, I observe, first, 
That the invasion of fever is frequently sudden. Dr. Fordyce 
remarks, " that he has known several instances where persons 
sitting down at the table with a strong appetite, an attack of 
fever having suddenly taken place, in less than two minutes 
they have been seized with perfect aversion even to the smell 
of food." p. 93. 

2. Fever occurs most frequently at night, when the body is 
most susceptible of irritation, especially those fevers which take 
place after exposure to cold, — as all inflammatory fevers, and 
especially in' children, owing to the greater sensibility of their 
system. Indeed this is the case in most inflammatory com- 
plaints. The same thing occurs in most nervous affections ; 
so with worms and other irritations of the bowels. So also 
with parturition. In like manner with fever proceeding from 
contagion, its operation is not perceived in the day, when the 
system is under other impressions, but shows itself at night 
when other stimuli are withdrawn. Dr. Fordyce remarks 
that in London, ten to one attacked with fever, are seized 
between 8 a. m. and 8 p. m., compared with those attacked at 



60 LECTURE IV. 

night, or from 8 p. m. to 8 a. m. This is certainly not the fact 
in this country. But we shall have frequent occasions to call 
in question the correctness of many of the opinions and obser- 
vations, even of that excellent observer, Dr. Fordyce. He 
may, perhaps, be correct in recording the phenomena of fever 
as they appear in Great Britain. But in America, in this in- 
stance, they are not applicable. 

3. Fever occurs too frequently under predisposition, arising 
from the state of the air, changes in its temperature and quality, 
and the condition of our fluids. We thereby frequently acquire 
a combustible state of body that is readily lighted up into 
fever. The northern man is readily inflamed by the rays of 
a tropical sun, and especially so when great numbers are con- 
gregated in small confined apartments, and the fluids of the 
system partake of the vitiated state of the air, produced by 
such confinement and want of ventilation. In such a fermenta- 
ble state of body, our fluids, like an impure atmosphere, are 
easily assimilated to the taint that may be introduced into them. 

The first symptoms of fever denote irritation in the nervous 
system, producing restlessness and uneasiness, both in the mind 
and body. In some the passion of anger is excited — the pa- 
tient, though originally of good temper, now quarrels with his 
best friends — takes offence even at every act of kindness. The 
mind becomes impatient, peevish, restless — passes rapidly from 
one object to another, and is incapable of steady mental exer- 
tion — the patient cannot think or reason even upon ordinary 
subjects with his usual ease ; and as the disease advances, 
the mind also becomes excited, and not unfrequently exhibits 
a character never known before. Senac informs us that he 
once knew a woman who, just before the paroxysm, became 
very loquacious, nor was the approach of the disease announced 
to the bystanders by any other sign — see Senac on Fevers, p. 
29. During the excitement of fever, in the case ofa lady, which 
occurred in this city, the imagination became so highly excited, 
that it displayed itself in a talent for poetry. Every thing she 
said during her paroxysms, was uttered in couplets, many of 
which were very correct and very beautiful. Yet she had 
never in health exhibited any extraordinary predominance 
of the imagination over the other faculties of her mind. In 



SYMPTOMS OF FEVERS IN GENERAL. 61 

another lady who, upon other occasions, had never been 
accused of wit, the mind was so powerfully influenced by the 
excitement of fever, that she uttered some of the most pointed 
expressions that the strongest intellect could have conceived. 
In one of those paroxysms, I requested her to put out her 
tongue. She did so. I requested her to put it out still farther 
— a little farther ma'am. — " Why, I believe, Doctor, you think 
there is no end to a woman's tongue," was her reply. Yet on 
no other occasion did this lady ever show the sudden and un- 
expected combination constituting wit. 

In the advanced stage of fever, it is known that delirium 
and even mania are not unfrequently among its attendant 
symptoms ; but in the very commencement of fever, the mind 
is similarly affected, though in a less degree, showing itself in 
great impatience and anxiety. Perception, memory, judgment, 
reasoning, are all more or less disturbed by the invasion of 
fever. The mind becomes hurried in all its movements, and 
acquires the same febrile state with the body. In some, the 
agitation is very considerable and very apparent, and attended 
with great anxiety — frequently analogous to that which appears 
in women at the approach of labour, and which irritation is 
of the same febrile character. 

But fever produces also, in other respects, an affection of 
the brain and nervous system, showing itself in the bodily 
organs as well as the mental. It produces pain of the head ; 
sometimes the forehead and eyes are more especially the seat 
of irritation. This is frequently the case in yellow fever and 
the plague. In other instances the nerves of the ear are pecu- 
liarly and violently affected, and in some instances the pain is 
exclusively seated in the posterior part of the head, the cere- 
bellum, producing stupor. 

Dr. Fordyce makes a distinction on this subject. He consi- 
ders the pain to be external in the first stage ! — but in the se- 
cond stage internal, which last he believes to be entirely the 
effect of the increased circulation in the carotids, and both 
occasionally producing delirium. His distinction is certainly 
not a just one ; the true explanation appears to me to be, that 
in the first stage, one cause is operating, viz. the impressions 
made upon the nervous system chiefly, if not exclusively. But 
in the second, two causes are co-operating to produce the 



62 LECTURE IV. 

same effect, i. e. the increased impetus of the blood is now 
added to the primary impressions made by the invasion of the 
disease on the nervous system — but which first impressions are 
in some instances so violent as to produce all which have been 
ascribed to both combined. The pain, therefore, attendant on 
the invasion of fever, cannot be considered as external in its 
operation. 

Pain also appears in the back, and that too, whether the 
patient be lying down or sitting up. Not, however, like the 
pain occasioned by debility after a fever, in which the patient 
is unable to sit up without an increase of it ; but like that 
which attends upon parturition — upon excessive venery, or is 
occasioned by self-pollution, which peculiarly affects the loins, 
and chiefly consists in irritation exclusively showing itself in 
the nervous system. So with fevers also : the irritation manifests 
itself upon the spinal marrow, and the principal nerves proceed- 
ing from it. Hence, too, the patient complains of pains in the 
limbs following the course of the larger nerves analogous to the 
pains of rheumatism. Sometimes, this pain is in one limb — most 
usually in both. This is especially the case in yellow fever and 
plague, and other fevers arising from contagion. The pain in 
some instances is so severe that- the patient feels as if his bones 
would be broken by it, (constituting the break-bone-fever, as 
Dr. Rush has denominated it,) attended in some cases with such 
distressing feelings as to be more appropriately called by the 
name given to it by a fair patient of the Doctor's, the break- 
heart-fever. A lady who was attacked with the same fever, 
experienced a very unusual degree of depression in her spirits. 
In her the disease vented itself upon her more tender feelings. 
She accordingly was thence led to give it the name of break- 
heart-fever. 

These pains denote frequently too the returning paroxysm 
of an intermittent, — pain of the back especially, though no other 
symptoms are present. 

Fever also produces a disinclination for bodily, as well as 
mental exertion. This has been very improperly called de- 
bility* by Dr. Cullen ; for the power of exertion is not lost, 
but suspended. And it applies equally to mind and body — for 

* It is a common error and often a fatal one, to mistake oppression for de- 
bility. 



SYMPTOMS OF FEVERS IN GEJfERAL. bS 

the paroxysm of fever being removed, the tone and vigour of 
both are restored, and at the time too when the debility is 
greatest, or should be so, i. e. when the paroxysm is ended. 

The nervous system manifests this invasion of fever in va- 
rious ways. In infancy and childhood it frequently shows itself 
in tremor, starting, dreams, talking in sleep, (somniloquism) 
walking in sleep, (somnambulism) subsultus tendinum, grinding 
the teeth, chattering of the teeth, rigours and convulsions. 
Dreams are not only the common attendants on the very first 
stage of fever, especially in children ; they are not only often- 
times premonitory of fever; but they also very frequently, in 
the process of fever, constitute the first degree of delirium in 
adults. 

In some cases, the adult is thus attacked. A patient of 
mine, upon the attack of an intermittent, was seized with con- 
vulsions, indicating the symptoms more of an apoplexy than 
of an intermittent fever, constituting what Alibert calls the 
apoplectic form of intermittent. Indeed, some old persons are 
thus seized with apoplexy, occasioned by the first invasion of 
fever. Hence it is said, that when an intermittent proves fatal 
to old persons, it does so during the first attack, and especially 
during the chill. Dr. Bard, senr., was thus affected in the first 
invasion of the disease which proved fatal to him. In every 
epidemic yellow fever with which the United States have been 
visited, some have suddenly died from this cause, and have 
dropped in the street, or have been found dead in their beds. 

The same thing has been observed of the plague. Lucretius 
tells us so in his description of the plague of Athens. Sydenham 
observes that during the first months in which the plague raged 
in London, people dropped down dead every day. In others, 
the invasion shows itself in stupor. 

These inflammatory symptoms attendant upon the first stage 
of typhus, I have many years since been apprised of — long 
before the publication of Dr. Armstrong's book. 

In other cases again, the patient becomes instantly maniacal 
from a state apparently of perfect health. It is recorded by 
Diodorus of the fever of Syracuse, that the sick instantly be- 
came delirious, and beat all who came in their way. A case is 
related by Dr. Gregory, in which a quartan was thus regularly 
announced by delirium, instead of the usual chill or rigor. 



64 LECTURE IV. 

Delirium we know to be the frequent attendant in every 
stage of fever. More commonly, however, the first stage of 
fever affects the nervous system by pain, tremor, and rigor, 
especially in children. In some I have seen it exhilarate the 
patient exceedingly. Children in hives frequently manifest this 
symptom before the disease shows itself in the blood-vessels. 

In other persons again, I have seen the invasion of fever 
produce hysteria, not only in women, but in men ; only, how- 
ever, in those of the nervous temperament, or who have 
created that temperament by intemperance. 

I have known an old gentleman thus attacked with hysteria, 
threatening convulsions. He was agitated, and sobbed like a 
young girl. 

In all persons you will observe great restlessness — the patient 
tossing from one side of the bed to another, except when stu- 
por is produced. Indeed, the whole frame is agitated and hur- 
ried ; it manifests itself in every act the patient performs. 
Upon giving him his drink, he receives it from you in haste — 
he takes it from you rapidly — he swallows it with the same 
hurry and agitation. If you ask a question, he answers you 
in the same impetuous manner. His respiration too partakes 
of the same hurry, and is frequently attended with great impa- 
tience, anxiety and heavy sighing, particularly in fevers arising 
from contagion. And let me add, that under such circum- 
stances, this is frequently a fatal symptom. 

The external senses are no less affected in the first stage of 
fever. The sense of vision manifests the irritation of fever — 
the patient complains of a degree of heat and burning in his 
eyes, attended with a great sensibility to light. In some in- 
stances it shows itself in an instantaneous and extraordinary 
redness of the eyes, attended with an inflammation of the 
glands, and an effusion of tears, and those of an acrid saline 
quality. These circumstances are frequently met with in the 
plague, yellow fever, influenza, measles, scarlatina, and other 
diseases proceeding from contagion. The state of the retina 
is also sometimes so much impaired, that the patient believes 
he sees a variety of objects passing before him which have no 
existence, the muscse volitantes, as they are thence denomi- 
nated. Motes of this kind are constantly created by this state 
of the nerves. In other instances the irritation shows itself in 



SYMPTOMS OF FEVERS IN GENERAL. 65 

producing an irregular action of the external muscles of the 
eyes. Strabismus or squinting is the consequence, and perhaps 
only exists during the irritation of fever. One of my own fa- 
mily is thus affected whenever any strong impression is made 
upon his nervous system, whether from fever, fear, or anxiety, 
but never squints at any other time. The sense of hearing 
is also affected. The patient hears imaginary sounds; the 
sensibility of the ear is so much quickened to real impres- 
sions, that he hears even the pulsations of the arteries of the 
ear. But this symptom occurs, as it regards both real and 
imaginary objects, more commonly in the advanced stage of 
fever, constituting what practical writers hence denominate 
tinnitus aurium. But where the sensibility of the constitu- 
tion is great, or the irritation of the disease is strong, this 
symptom exists from the first. The taste is in like manner de- 
praved and vitiated, insomuch that the patient scarcely distin- 
guishes his medicines from his food .or his drinks. Whereas, 
before, his sense of taste may, perhaps, have been very acute. 
The sense of smell is also frequently impaired or even sus- 
pended. The feeling is especially affected. In some instances 
the patient supposes he feels insects creeping over his skin, or 
hairs pricking him : some are insensible to heat. A case 
once occurred to me of a person who was severely burnt, by 
the application of a hot iron in the commencement of fever. 
The same patient was confined three months by an ulcer thus 
produced. More commonly, however, the patient complains 
of great coldness, when the body is even preternaturally heated ; 
and this too to a degree of shivering, called horripilatio, mak- 
ing the papillae of the skin and the very hairs erect them- 
selves. Hence the origin of the term. As an evidence of this 
sense of coldness, although the patient may be unusually co- 
vered, he complains that he wants more clothes, or wants to 
approach the fire — calls for hot drinks — takes them much hotter 
than he could possibly do in health ; and all this time the body 
is perhaps preternaturally heated, as shown by the thermo- 
meter. Frequently, however, the heat is actually reduced by 
the first irritations of the nervous system — and the circulation 
diminished in the small vessels upon the extreme parts of the 
body — and the extremities become cold, especially when the 
7 



68 LECTtffiE V, 

communis choledocus, or the urinary calculus in the ureter- 
sometimes excites the most severe rigours. A catheter in the 
bladder — an enema in the rectum— caustic applied for stric- 
ture of the urethra — strangulation of the intestines — hemor- 
rhagic affections— pus in the blood-vessels, I have known to 
produce similar rigours without any peculiar affection of the 
stomach. 

A case is related by Senac, of a soldier who died of a ri- 
gour that lasted two days, induced by a krge abscess in the 
liver. The rigours, therefore, in an intermittent, upon the same 
principle, may be accounted for as the result of an analogous 
irritation of the nervous system, occasioned by the usual causes 
of intermittents, particularly marsh effluvia. But we may 
easily account for the mistake of Dr. Fordyce, when we take 
into view the extensive connexions which the stomach holds 
with the nervous system* T)y means of its ganglions— its nerves 
— -the cseliac plexus — the great intercostal, and its immediate 
correspondence with the brain through the intervention of the 
eighth pair or the par vagum, constituting the stomach, as I have 
already expressed it, a sort of second brain in the system. By 
referring to Whytt's experiments, and still more recently, those 
of Wilson, the tying of the eighth pair in a dog, you will see 
the injury it occasioned in impairing the functions of the sto- 
mach. 

It is certainly surprising that Dr. Fordyce, with bis long ex- 
perience, his talent for investigation, and his acquaintance with 
pathology, should have had so limited, so short-sighted a view of 
this subject, as to refer those phenomena to a single organ- 
The whole body should be looked at. The body, like a build- 
ing, should be surveyed in toto, and all its parts io connexion 
taken into view. They should be viewed, too, at a proper dis- 
tance — every object has its focal distance — we should not 
merely see the fly on the castle. Clutterbuck, in like manner, 
saw nothing but the brain amidst all the phenomena which 
fever produces ! ! His doctrine traces all fever, forsooth, to 
inflammation of the brain ! It would be wasting your time, 
gentlemen, to notice the absurdity of Dr. Clutterbuck's whims 
on this subject — you may read his book if you please, to see to 
what ridiculous lengths a man will suffer himself to be carried 
by a favourite notion. 



OF FEVERS IN GENERAL. 69 

The same remark will apply to the fanciful theories of some 
recent writers of the French school, who refer all fever to in- 
flammation of the mucous lining of the alimentary canal. 
Every thing with these new-fangled pathologists, is gastroente- 
ritis! Risum teneatis, amici '? But a Frenchman, you know, 
is very apt to think a great deal about his stomach ! The truth 
is, these new-fashioned theorists mistake the effect for the cause. 
The post-mortem appearances to which they so triumphantly 
appeal as evidence of their doctrine, are generally nothing more 
than the results of the disease ; often they are the effects of 
acrid medicines, and other injudicious prescriptions ; frequent- 
ly, the changes produced by the very act of dying, or con- 
sequent upon death ;* and perhaps, even more frequently, 
nothing more than the proofs that the patient has perished be- 
cause his physician has, instead of properly cleansing the pri- 
mcevicB, permitted the vitiated secretions and offensive contents 
of the bowels to overload them, and remain pent up to be an 
additional source of irritation to their highly sensitive surfaces, 
and to, the system at large. And yet, this is the doctrine so 
vaunted among us in the present day, and which threatens to 
become the popular theory of fever. So long, however, as the 
wretched, temporising practice which must result from it, is , 
pursued, there will not be wanting abundant post-mortem proof? j 
that fever is nothing more than g astro-enteritis. If you wouli 1 
be enlightened physicians, and successful practitioners, yo u 
must take more general views than those which will lead you 
to look only at the internal coat of the stomach and bowels for 
the causes and phenomena of fevers. 

But fever also shows itself in the muscular fibres of the vas- 
cular system. Not only the heart is in general excited to 
more frequent contractions, but the arteries also. — The natural 
standard of the pulse in the adult, in health, is seventy-three. 
You will recollect that the circulation differs at different ages 
— that in a new-born infant the pulse is about one hundred and 
forty — towards the end of the first year, about one hundred 

* Upon the inspection of dead bodies, there has been repeatedly observed a 
remarkable turgescence of the vessels of the stomach and intestines, when the 
individual has died suddenly, without having ever manifested in life the least in- 
dication of disease in these organs. The vessels I have seen strongly injected 
even in cases of death from casualties occurring in perfect health 
7* 



68 LECTCfku V, 

communis choledocus, or the urinary calculus in the ureter- 
sometimes excites the most severe rigours. A catheter in the 
bladder — an enema in the rectum— caustic applied for stric- 
ture of the urethra — strangulation of the intestines — hemor- 
rhagic affections — pus in the blood-vessels, I have known to 
produce similar rigours without any peculiar affection of the 
stomach. 

A case is related by Senac, of a soldier who died of a ri- 
gour that lasted two days, induced by a krge abscess in the 
liver. The rigours, therefore, in an intermittent, upon the same 
principle, may be accounted for as the result of an analogous 
irritation of the nervous system, occasioned by the usual causes 
of intermittents, particularly marsh effluvia. But we may 
easily account for the mistake of Dr. Fordyce, when we take 
into view the extensive connexions which the stomach holds 
with the nervous systenfby means of its ganglions— its nerves 
— -the casliac plexus — the great intercostal, and its immediate 
correspondence with the brain through the intervention of the 
eighth pair or the par vagum, constituting the stomach, as I have 
already expressed it, a sort of second brain in the system. By 
referring to Whytt's experiments, and still more recently, those 
of Wilson, the tying of the eighth pair in a dog, you will see 
the injury it occasioned in impairing the functions of the sto- 
mach. 

It is certainly surprising that Dr. Fordyce, with his long ex- 
perience, his talent for investigation, and his acquaintance with 
pathology, should have had so limited, so short-sighted a view of 
this subject, as to refer those phenomena to a single orgam 
The whole body should be looked at. The body, like a build- 
ing, should be surveyed in toto, and all its parts in connexion 
taken into view. They should be viewed, too, at a proper dis- 
tance — every object has its focal distance — we should not 
merely see the fly on the castle. Clutterbuck, in like manner, 
saw nothing but the brain amidst all the phenomena which 
fever produces ! ! His doctrine traces all fever, forsooth, to 
inflammation of the brain ! It would be wasting your time, 
gentlemen, to notice the absurdity of Dr. Clutterbuck's whims 
on this subject — you may read his book if you please, to see to 
what ridiculous lengths a man will suffer himself to be carried 
by a favourite notion. 



OF FEVERS IN GENERAL. 69 

The same remark will apply to the fanciful theories of some 
recent writers of the French school, who refer all fever to in- 
flammation of the mucous lining of the alimentary canal. 
Every thing with these new-fangled pathologists, is gastroente- 
ritis! Risum teneatis, amici '? But a Frenchman, you know, 
is very apt to think a great deal about his stomach ! The truth 
is, these new-fashioned theorists mistake the effect for the cause. 
The post-mortem appearances to which they so triumphantly 
appeal as evidence of their doctrine, are generally nothing more 
than the results of the disease ; often they are the effects of 
acrid medicines, and other injudicious prescriptions ; frequent- 
ly, the changes produced by the very act of dying, or con- 
sequent upon death ;* and perhaps, even more frequently, 
nothing more than the proofs that the patient has perished be- 
cause his physician has, instead of properly cleansing the pri- 
mcevifz, permitted the vitiated secretions and offensive contents 
of the bowels to overload them, and remain pent up to be an 
additional source of irritation to their highly sensitive surfaces, 
and to, the system at large. And yet, this is the doctrine so 
vaunted among us in the present day, and which threatens to 
become the popular theory of fever. So long, however, as the 
wretched, temporising practice which must result from it, is , 
pursued, there will not be wanting abundant post-mortem proof* j 
that fever is nothing more than g astro-enteritis. If you would 
be enlightened physicians, and successful practitioners, yo u 
must take more general views than those which will lead yc >xx 
to look only at the internal coat of the stomach and bowels for 
the causes and phenomena of fevers. 

But fever also shows itself in the muscular fibres of the v;as- 
cular system. Not only the heart is in general excited to 
more frequent contractions, but the arteries also. — The natural 
standard of the pulse in the adult, in health, is seventy-three. 
You will recollect that the circulation differs at different agetf 
— that in a new-born infant the pulse is about one hundred and 
forty — towards the end of the first year, about one hundred 

* Upon the inspection of dead bodies, there has been repeatedly observed a 
remarkable turgescence of the vessels of the stomach and intestines, when the 
individual has died suddenly, without having ever manifested in life the least in- 
dication of disease in these organs. The vessels I have seen strongly injected 
even in cases of death from casualties occurring in perfect health 
7* 



70 LECTURE V. 

and twenty-four — in the second year, one hundred and ten — 
in the third and fourth, ninety-six — -at puberty, eighty — in 
manhood, seventy-three — at sixty, about sixty. Instead of se- 
venty-three or seventy-five pulsations, they are quickened from 
that number to ninety, one hundred, one hundred and ten, one 
hundred and twenty in a minute — occasionally to one hundred 
and forty or one hundred and fifty strokes, depending upon the 
habit of body, the sensibility of the system, the type and cha- 
racter, as well as the cause of the fever, and the depletion the 
person may have undergone. This greater frequency of the 
circulation, though it does not take place in all instances, is 
generally present in fevers of the continued form ; i. e. in the 
second or hot stage ; but even then, it sometimes happens, that 
although all the other symptoms of fever may be present, the 
pulse, and in continued fevers too, is not more than seventy- 
three, the natural standard of health. Indeed in some cases, as 
before observed, Fordyce has seen it below seventy-three, yet 
all the other symptoms of the second stage of fever were pre- 
sent. From which it appears that the heart and vessels are in 
some cases not so much acted upon as the other parts of the 
body. So with yellow fever; the patient dies with black 
vomit, yet the pulse throughout is calm, soft, full and appa- 
rently healthy. 

A pupil of mine, (Dr. Marx,) informs me that the same fact 
has been noticed by Dr. Glover of Charleston, S. C. in a patient 
of his who died with the yellow fever, that the pulse had been na- 
tural throughout his disease, and that Dr. Glover has related the 
iase to the Medical Society of that city, noting this peculiarity. 

This disease frequently operates, I had almost said exclusively 
jpon the nervous system, affecting not only the brain but the 
nerves of the stomach, and other branches of the cseliac plexus. 
Indeed the stomach has been very properly denominated by 
Dr. Warren, of Barbadoes, the " seat and throne of the dis- 
ease," in yellow fever; for frequently other parts of the system 
remain relatively undisturbed. Even the muscles, in some cases, 
retain their power to the last moment of life ! They are so little 
affected by the irritations of that fever, that I have known 
the patient to rise from his bed, dress himself, and walk about 
his chamber until his hearse was at his door, ready to receive 
his body. Such was his muscular power that he could dig 
his own grave ! 



OF FEVERS IN GENERAL. 71 

Analogous peculiarities have been remarked in the plague 
and in the spotted fever : but they are not found as the attend- 
ants on fevers in general, as they rather constitute exceptions. 

But to return to our subject. In the first stage, or the inva- 
sion of fever, the smaller arteries of the surface of the body 
are preternaturally contracted and diminished in their diameters. 
Less blood flows into them — the surface becomes pale ; and with 
less blood there is also less heat ; for heat is generally in pro- 
portion to the quantity of blood carried to a part — this fact we 
must all have witnessed. The hands, after riding in the cold 
air, and coming into a warm apartment, or suddenly exposing 
them to the intense heat of the fire, are not only attended with 
swelling but great increase of heat also, in proportion to such in- 
flux. So in fever the heat accumulates with the blood ; and the 
quantity of blood being diminished in the first stage, the extre- 
mities are cold. This, it is to be observed, occurs much more 
frequently in fevers arising from marsh miasma, as intermit- 
tents or remittents ; but less so in yellow fever ; yet it is not 
unfrequently the case in small-pox, typhus fever, and the phleg- 
masise. 

The exhalent, as well as the circulating arteries, are also ex- 
cited to preternatural contraction ; their extremities, in particu- 
lar, are contracted or spasmodically affected. This is so fre- 
quently the case that Dr. Cullen considers spasm the cause of 
the fever. Is it not more probably the effect of the fever, or of 
the irritation producing fever, analogous to the small pulse in 
gastritis, enteritis or phreiitis, and other membranous inflam- 
mations, or inflammations seated in very sensible parts of the 
body? 

Dr. Rush calls fever a convulsive action of the blood-vessels. 
This is but another expression to show the irritation which fe- 
ver produces in this as well as other parts of the system. This 
stricture, spasm, or convulsed state, of the exhalent vessels, 
shows itself throughout the system in the excretions. 

1. The saliva is diminished in quantity, and the mouth be- 
comes parched and dry. The tongue, too, is dry ; its papilla? 
are erected by the retraction and stricture which take place 
upon the intermediate pirts ; and usually is attended with great 
thirst. 

2. The urine is limpil, pale, white, and diminished in quantity 



72 LECTURE V. 

— the bladder, as well as the vessels of the kidneys, manifests the 
effect of this irritation by its contraction and. disposition to eva- 
cuate itself frequently during the invasion of fever ; and that irri- 
tation will produce this effect we have an illustration in the 
effects of hydrophobia. In a dissection made of a person who 
died of hydrophobia, by the late Dr. Andrew Marshall, of Lon- 
don ; and by whom I was informed of the fact, in 1793-4 ; 
the urinary bladder was found preternaturally contracted. 
(See the same as related in his life, published by Mr. Sawyer, 
one of his pupils.) The same thing has been stated in accounts 
of other dissections, where death had been occasioned by that 
disease. 

3. The skin is contracted in fevers — exhibiting the cutis an- 
serina — the constriction is even manifest to the eye, like a 
muscle wrinkled as well as contracted — almost the same con- 
striction is apparent in the human body as takes place in the skin 
of horses, which is supplied with a distinct muscle, the pan- 
niculus carnosus. Whenever that animal is diseased by fever, 
this muscle becomes affected, and the horse is said to be hide- 
bound. The skin, in fevers, also becomes dry and harsh, losing 
its natural softness, and no evaporation taking place, the circu- 
lation at the same time being increased, the heat of the body 
accumulates ; for the fluid secreted by the skin in health being 
converted into vapour, necessarily takes off a portion of the 
body's heat. In this way cold is produced by evaporation. Upon 
the same principle the atmosphere is cooled on a hot day by a 
shower of rain — the heat or caloric being absorbed in the con- 
version of water into vapour — in the practice, too, of cooling 
liquors by moistening the bottles containing them, the heat of 
the liquor is communicated to the surrounding moisture, which 
it converts into vapour, leaving the contents of the bottle rela- 
tively cold. In this way the human body might be frozen in 
the month of July. Upon the same principle, perspiration going 
on, Sir Charles Blagden, Dr. Fordyce and others, were enabled 
to bear the extraordinary degree of heat (300°, 400°) to which 
they were exposed in their experiments ; and which was great 
enough to broil beef-steaks, or to cook eggs. The use of the 
fan, instead of cooling them, burnt t;hem by bringing a new 
stratum of hot air into contact with the surface of their bodies, 
which had been cooled by the abstraction of heat that took 



OF FEVERS IN GENERAL, 73 

place in converting the perspirable fluid into vapour. The want 
of this cooling process, therefore, as already observed, occasions 
our heat to accumulate, and thereby to become an additional 
source of febrile excitement. 

4. The lungs, too, undergo a corresponding change in their 
functions. In phthisis we see expectoration diminished during 
the paroxysms of the hectic fever attendant upon that disease 
— in pneumonia the same thing occurs. We see the same in 
fevers in general. 

5. The stomach, as is to be expected, manifests the evidences 
of the same irritation in loss of appetite— a morbid appetite — 
nausea, vomiting, suspension of the digestive process, as is 
evident from the food being long retained. — The gastric liquor is 
also probably both diminished in quantity and altered in its 
quality, analogous to the changes we see take place in the se- 
cretions of an ulcer. Hence it appears that intermittents and 
diseases cf contagion are ushered in most generally by nausea 
and vomiting because they make strong impressions on the nerv- 
ous system. The great semi-lunar ganglion and the numerous 
nerves of the stomach cannot escape the commotion produced 
by fever upon the nervous system. 

6. The liver is no less affected than the stomach in the first 
stage of fever ; but in the hot and sweating stages its secretions 
are oftentimes increased, showing this effect in a catharsis or 
increased evacuations ; and those, too, exhibiting the appearance 
of bile recently secreted. 

7. As to the pancreas, we have no evidence of such change, 
but the presumptive. 

8. In the intestines the secretion of fluids is obviously dimi- 
nished ; hence costiveness is the usual attendant. The thinner 
fluids, that had been secreted, are also probably reabsorbed. 
Accordingly in the first stage of fevers the faeces are not liquid, 
but come away in a solid form, as we see upon giving an 
enema at this time. This is not all ; it frequently happens that 
even after a cathartic or an enema, we find very unexpected 
discharges of scybala to take place, which had been long pent 
up probably by some irregular and partial contractions of the 
intestinal canal itself. This event frequently occurs in fevers ; 
and especially in the advanced stage ; oftentimes just before 
death, when such stricture may be removed by the universal 



74 LECTURE V. 

relaxation of the frame. In dysentery, where evacuations have 
not been sufficient in the first stage of the disease, such dis- 
charges frequently show themselves just before dissolution, and 
to the great reproach of the physician. In diseases of the in- 
testines themselves, we know by dissection afterwards, that 
such stricture or preternatural contractions have taken place ; 
and that lodgments of faeces have thus been formed. (See 
Baillie's Morbid Anatomy.) In fevers we also see this con- 
traction by the small discharges that take place, and that the 
same irritation contracts the bowels that we know to affect the 
bladder. 

9. Uterus. The menses are in like manner checked by fever, 
when they may have been flowing at the time of the patient's 
attack, and the lochia in puerperal fever are in the same way 
diminished. Indeed this diminution is among its first symp- 
toms, and proves an additional source of malignancy in that 
peculiar form of fever that follows parturition. 

10. The milk, too, is diminished, sometimes totally dried 
away ; not only during the paroxysm, but frequently this aga- 
lactia remains after the fever has terminated. 

11. Ulcers are dried up and their colour changed during the 
action of fever. Blisters become pale and cease to discharge 
— hence it is a bad symptom to see blisters rapidly healed — it 
being an evidence of the diminished secretion from the surface 
and the accumulation of great heat in the part. 

12. The extremities also shrink — rings which before were 
tight now drop off. The wedding ring is frequently dropped 
on this occasion, and this by the superstitious is considered a 
bad omen. 

The pulse also partakes of the changes going on in the sys- 
tem. In the first stage the pulse is small — it is small from an- 
other cause than the preternatural constriction of the artery ; 
probably there is less blood to dilate it ; i. e. the irritation, 
the cause of the disease, occasions the artery to contract upon 
less blood, and its contractions are more frequent — the heart 
and larger vessels consequently become in proportion full. 

The pulse, I should here remark, is of different kinds; and 
conveys different sensations to the physician, which are ex- 
pressed accordingly. I shall not amuse you with a recital of 
the numerous varieties of the pulse noticed by some nations, as 



OP PEVERS IN GENERAL. 75 

the Chinese, who count three thousand pulses : nor even the 
variety described by Dr. Rush. 

I distinguish at the bedside ten varieties of pulse — 

1. The full pulse, which dilates itself unrestrained. 

2. Small pulse, scarcely to be perceived. 

3. The soft pulse, readily yielding to pressure. 

4. Hard or chorded, terse, wiery or quilled pulse ; i. e. not 
easily compressed, but making great resistance under the finger, 

5. The frequent or quick pulse, in which one pulsation rapidly 
succeeds to another. Some distinguish between the frequent 
or quick pulse, referring in the last to the quickness or jerk 
with which the artery contracts, and not the rapidity as it re- 
gards the number of pulsations. This is an useless distinction, 
for they both show the same irritation operating upon the heart 
and vessels. 

6. The slow pulse — one beat slowly succeeding to the other, 

7. The regular pulse — the intermission between the beats 
being the same. 

8. The irregular pulse — the intervals being irregular. 

9. The intermittent — where some pulsations are wanting — 
This is common in hydropic affections of the chest — also com- 
mon in gastric and hepatic affectkwis, and is more frequently 
symptomatic of those diseases than of any mal-organization 
of the heart or its valves — in angina pectoris — in organic af- 
fections of the heart, and also in nervous affections — palpi- 
tations. 

10. The gaseous pulse — giving the idea of air instead of 
blood filling the vessel — the soap-bubble pulse of Dr. Rush, as 
it was unfortunately called. The manner of feeling the pulse 
merits a moment's attention. 

1. Do not feel the pulse too soon after you have entered the 
room. Allow the first impressions made upon your patient by 
the approach of a new object to subside. 

2. Let your patient's arm lie in an easy position, so that the 
pulse may not be excited by the action of the muscles, as would 
be the case in extending the arm to the physician. 

I 3. For the same reason, if your^. patient has just been getting 
out of bed, or has been moved in bed, wait for the subsidence 
of the effects of such movement. 

4. Do not exclusively confine yourselves to the pulse at the 



76 LECTURE V. 

wrist — sometimes the carotids or temporal arteries manifest the 
chief irritation of the disease. 

5. In feeling the pulse, make use of two fingers instead of 
one — they correct each other's sensations — and as the fingers 
have nicer sensibility than the thumbs, the fingers are preferable 
for this operation. 

It is a good rule, too, to feel the pulse in both arms — for fre- 
quently you meet with a great difference, particularly as it re- 
gards the size and strength of the artery. 

6. This leads me to observe that for this purpose it will be 
important for you to cultivate a nice sense of feeling at the 
extremities of your fingers. This you will best do by the prac- 
tice of wearing gloves — at the same time that you thereby 
preserve your hands at a proper temperature, so as thereby to 
ascertain the temperature of your patient. The physician need 
not frighten the women and children by wearing a muff, as 
was the practice of the elder Dr. Shippen, of Philadelphia, and 
of the elder Dr. Bard, of this city ; but every physician should 
protect his fingers by wearing gloves, that their sensibility as 
well as their proper temperature may be preserved. 

Upon many occasions, too, let me tell you, that you require 
all the sensibility you can command in the extremities of your 
fingers. You want it, in some instances, to detect the presence 
of pus when deep seated — or of water in the cavity of the belly 
— or in the ovarium. We also require a nice sense of touch 
in feeling a vein for the purposes of venesection, especially in 
young and fat children. The late Rev. Dr. McDonald, of 
Albany, came one hundred and sixty miles for the purpose of 
getting bled. The physicians of the town where he resided 
could not effect the operation. They could not perceive the 
vein under the stratum of fat that covered it. So in cases of 
croup it is very difficult, unless you are habituated to the sen- 
sation, to find a vein. 

For these purposes then cultivate this sensibility — this know- 
ledge at our fingers' ends is highly important — you will find it 
upon many occasions no less useful to the physician than to 
the surgeon. In the practice of midwifery, this nice touch is 
peculiarly necessary, not only in conducting labour, in ascer- 
taining the presenting part of the child, and the dimensions 
and condition of the organs concerned, but in directing the 



OF FEVERS IN GENERAL. 77 

introduction of the catheter, which the accoucheur is frequently 
called upon to perform. Another good rule in feeling the pulse 
is, to concentrate our sensations in the fingers. This is done 
by closing the eyes, and thereby excluding impressions received 
by the other senses. Noise or even music, at our meals, we 
well know, impairs, if it does not destroy the sense of taste — 
so does a variety of objects upon the eye diminish and divert 
the sense of feeling. Noise in the bystanders, at an operation, 
frequently disturbs the operator. The cries of the patient have, 
upon some occasions, very much interfered with the sensations 
of the person performing an operation. I once, when operating 
for aneurism upon a lad, for a few moments found it diffi- 
cult to feel even the pulsations of the femoral artery that I 
wished to detach, to put a ligature around it, until I could ab- 
stract myself by concentrating my sensations in my fingers. 

I make but one remark more on this collateral, but certainly 
not unimportant matter. Never time the patient's pulse by a 
watch. It alarms, without communicating any information 
w T orth having. It may prove a death-watch to the sick ! — 
But to return to ihe subject. 

As fever advances to the second stage, the pulse becomes 
more frequent and tense, hard, chorded, communicating to the 
fingers a sense of sharpness, more especially when fever is at- 
tended with inflammation seated in sensible parts of the body, 
as the intestines ; or with inflammation of the surface, as in 
erysipelas and other cutaneous diseases, and inflammation of 
the uterus, &c. ; or of parts which become highly sensible 
when inflamed, as the dense membranes, the serous mem- 
branes, as Bichat calls them — such as the membranes of the 
chest — those of the liver, and those of the brain. The pulse 
manifests the irritation, not only by its frequency, but by its 
hardness, in the first and second stage. 

It is an observation, as before remarked, made by Hippo- 
crates, that sometimes while the arteries at the wrist are weak 
and small, the carotid and temporal arteries are strong, and the 
case is attended with coma ; and in some cases by acute, 
deep-seated pain in the head. These dangerous symptoms, as 
remarked by Sir J. Pringle, in some cases denote inflammation 
of the brain, and abscesses are sometimes the consequence. 
Another observation worthy of your notice is, that the irritation 
8 



78 LECTURE V. 

in the pulse is sometimes perceptible to the physician, while the 
patient is not conscious of any departure from a healthy state 
in his feelings. I have, in this way, oftentimes known in the 
morning, from the indication manifested by the state of the pulse, 
whether my patient would have a return of an intermittent, and 
have predicted it ; while in other instances I have thus been 
enabled to prevent its recurrence. 



79 



LECTURE VI 



OF FEVERS IN GENERAL. 



The phenomena which have been noticed as the attendant 
symptoms of fever, appear not only in the paroxysm of an 
intermittent, but also in an ephemera, in synocha, typhus, 
the phlegmasia?, and many eruptive diseases, as small-pox, 
measles, &c. They appear even in tetanus and in hydropho- 
bia, when inducing fever by the irritation of the nerves, the 
primary seat of those diseases. For irritation, thus applied 
and continued, will produce fever. Not so, says Fordyce ! — 
But we do see it even in tetanus and in hydrophobia. — See Dr. 
Rush's las^ publication on the hydrophobic state of fever, as 
he denominates it, in a letter which he did me the honour to 
address to me. Also, see Dr. Shoolbred's valuable paper on 
that subject, in which he relates some cases cured by treating 
it as fever, i. e. by venesection, and other depleting remedies. 
See Med. Phil. Register — Eclectic Repertory of Philadelphia. 
See also, Dr. Andrew Marshall's Observations on Hydrophobia, 
in which the effects of fever and inflammation are manifest in 
various parts of the system. 

I refer you to these cases, not for the purpose of showing 
that they are necessarily febrile diseases, but that nervous irri- 
tation will extend itself to the blood-vessels by its continuance. 
Pain alone, if long continued, will also produce fever, as in 
cases of calculi of the gall bladder, kidneys, urinary bladder, 
the pain from spasm of the uterus, intestines, &c. The pains 
of labour are frequently attended with fever, which in some 
instances is of considerable duration. Indeed, in the process 
of labour you recognise the symptoms of a paroxysm of an 



BO LECTURE VI. 

intermittent. The first irritations beget a chill; the hot and 
sweating stages succeed. 

So far as irritation begets fever, we may say with Dr. Rush, 
that fever is unit ; but assuredly the character and duration of 
the disease are changed, influenced, and varied by the causes 
producing il ; and, as has already been pointed out, by the parts 
of the body becoming affected. I say, by the causes pro- 
ducing fever, and the structure and sensibility of the parts 
affected by such fever. 

Thus, synocha arising from the sensible qualities of the at- 
mosphere affecting the mucous membrane, produces catarrh, 
or cynanche tonsillaris ; and these are afterwards frequently 
renewed by the consequent irritability of those parts upon the 
least change of dress, of air, or both combined. In this way 
we see some of the most alarming diseases induced. Our 
families in their attendance upon our dancing assemblies, by 
their sudden exposure at first to the air of hot rooms, and 
afterwards to the cool atmosphere, when heated by the violent 
exercise of dancing, and sometimes from other causes, with 
their bodies half naked, frequently thus ensure catarrh, he- 
moptysis, and pulmonary consumption. 

These causes first excite general fever ; but pain and excite- 
ment in the irritable part are also among the first symptoms, 
the effects of such general fever upon the system. 

In some persons the same synocha or general fever locates 
itself in the lungs, producing pneumonia. In others, the liver 
becomes affected, and hepatitis is produced. 

The skin sometimes becomes the seat of irritation, producing 
erysipelas. Nothing is more common than these eruptive dis- 
eases at the approach of winter, in consequence of the check 
of perspiration and a general febrile state of the system; 
while in others it shows itself upon the muscles and joints, 
in the form of gout and rheumatism. Hence the common ex- 
pression that the gout cures all other diseases, or takes the 
place of all others. If I could get a fit of the gout, says the 
free-liver, I should be a well man : that is, all his disagreeable 
feelings which affect him in different parts of the body, would 
be concentrated in his great toe. In other words, he would have 
one seat of irritation instead of many. In some again, the 
bowels are the irritable organs, and enteritis is the consequence.. 



OF FEVERS IN GENERAL. 81 

In like manner the breasts, the uterus, or the lower extremi- 
ties of lying-in women, are easily affected at the time of partu- 
rition, and inflammation of those parts of the body is frequently 
then produced by causes which, under other circumstances, 
would perhaps only occasion a slight indisposition or a com- 
mon catarrh. 

Accordingly, then, as the part is more or less irritable, either 
from its greater sensibility, natural or acquired, or from its 
previously having been the seat of disease, it becomes again 
the seat of irritation — the place of rendezvous. 

A fellow student of mine at the University of Edinburgh, 
Decastro of Vienna, informed me that his mother had suffered 
twenty-one attacks of pleurisy, and ten of hives; and Dr. Ferdi- 
nand Ludlow, a student of mine, I am sure I attended for croup 
nearly as often : not a season passed until his twelfth year, that 
he had not several attacks of it, such was the irritability of 

his trachea and bronchiae. Mr. T P 1, jun., also, in 

his infancy suffered many attacks of croup, attended with 
symptoms of asthma. He now suffers bronchitis upon every 
exposure to cold. 

Fever, therefore, varies in its character according to the 
causes producing it, and the condition of the part affected. 

Let me here call your attention to the error of Fordyce, 
(p. 19, 20,) who makes those local inflammations the primary 
disease, instead of the effects of general fever occasioned by 
the sensible qualities of the atmosphere ! He even considers 
phlegmon and sphacelus, as primary affections in diseases ! — 
When occurring in fevers they certainly in many cases are not 
so. The bubo and carbuncle that appear in plague and yellow 
fever, although they appear early, are unquestionably the 
effect of general not local irritation, and that too in the first 
instance. So also the sore-throat in the commencement, and 
local inflammation or sphacelus which occasionally super- 
venes in typhus, are ascribable to the same general affection 
of the system. I have seen a case of an affection of the ankle 
joint in typhus fever prove fatal. I know another who is now 
suffering severe local disease proceeding from rheumatism, 
the effect of sea-bathing when heated by previous exercise* 
Hydrocephalus is also thus produced, in some instances, as the 
result of general fever. And you have seen in the present sea- 
8* 



82 LECTURE VI. 

son, 1822, a case of fever ending in carbuncles, filled with 
purulent matter, and which in that case terminated fatally. 

Riverius (see his Prax. Med. lib. 27. cap. 2. Appendix,) ob- 
serves, that acute and dangerous fevers very rarely occur with- 
out producing some local congestion or inflammation of some 
of the viscera — " Rarissime fieri sine interna et peculiari vis- 
ceris cujusdem affectione et plerumque inflammatione ; quare 
nunquam omittenda cura hypochondriorum, capitis, thoracis, 
uteri, renum, et vesicas ; ut omni ratione investigamus quse 
harum partium insigniter laboret, et ei, quoad fieri potest, 
subvenietur." 

Dr. Donald Monro observes, that in fatal or malignant 
fevers, " the febrile matter is apt to fall on particular parts, and 
there to create abscesses, particularly in the brain, the lungs, 
and in the glands and organs." Diseases of Military Hospitals, 
vol. i. p. 237. 

Affections of the brain are frequently noticed by authors as 
the consequences of general fever, as showing themselves in 
inflammation, in effusion of serum, or in suppuration, espe- 
cially in the cerebrum, and indeed in the cerebellum occasion- 
ally. The cerebellum is said to be comparatively little affected. 
Two cases, however, of abscesses in the cerebellum are no- 
ticed by Pringle, as produced by remitting fever. Eisfield, in 
his account of the yellow fever of Leipsic, in 1799, mentions 
a case of abscess in the brain thus produced. In the epidemic 
fever of Geneva, in 1805, congestions of the brain were fre- 
quent occurrences. A similar condition of the organ was also 
observed by Jackson, to be the effect of yellow fever. And in 
examinations made in this country, this engorged state of the 
brain was also frequently observed, and occasionally a rup- 
ture of the vessels producing sudden death. There was a 
case at Bellevue, prescribed for by Dr. Rayley, in which the 
patient, apparently convalescent and sitting up in bed, sud- 
denly fell back dead — an effusion of blood upon the brain was 
found upon dissection. 

De Haen also mentions inflammation and sphacelus of the 
bowels as the frequent attendant on remitting fever, as disco- 
vered upon dissection. Pringle too states, that in northern 
climates rheumatism was an attendant upon intermitting fever. 
In 1822 and 1823, a case of this compound character occurred 



OF FEVERS IN GENERAL. 83 

in the New York Hospital, in which the intermittent and rheu- 
matism appeared alternately. When the one appeared the 
other yielded — in this manner too, frequently changing places. 
In like manner fever, after exhibiting its idiopathic character, 
sometimes fastens on the lungs and terminates in pneumonic 
inflammation. Many years since a case of this nature occur- 
red under the care of Dr. Richard Bayley. The disease began 
as an intermittent, and preserved its character a long time as 
such, but ended in pulmonary inflammation and ulcer of the 
lungs. A case of this nature was also presented in the hos- 
pital, in which it began as rheumatism, but in a little time 
manifested a tendency to phthisis ; and another of an intermit- 
tent ending in a similar manner. Inflammation of the stomach 
is recorded by Bartholin, as attendant upon the remittent fever 
of Copenhagen. The same fact was noticed by Silvius de la 
Boe, in the epidemic of Leyden. 

Fordyce even asserts that fever does not give a tendency to 
sphacelus, p. 21. Had he seen either of the cases I have al- 
ready referred to, of the fever falling upon the ankle joint, or 
upon the knee, and ending in rheumatism and abscesses, he 
would probably have expressed himself differently on this sub- 
ject ; or had he seen the black man in the hospital in 1822, in 
whom the sacrum was laid bare by inflammation and ulcer 
supervening, in a typhoid remittent, he would have changed 
his views upon this important subject. Dr. Fordyce farther 
errs, when he says, that by removing the local inflammation, 
you remove the general fever. This is indeed taking a nar- 
row, contracted view of the subject, not to observe the in- 
tervention of the whole system in producing the phlegmasia?. 
I say, by removing the general febrile symptoms, you re- 
move the local inflammation, unless it be far advanced towards 
the usual terminations of inflammation. But even then you 
moderate it ; and again I assert, that the most effectual reme- 
dies are those which act on the whole system, and not upon 
the part affected. 

Dr. Fordyce himself mentions, p. 24, a case of fever Conti- 
nuing and going through a long course of typhus, after pneu- 
monic inflammation had been removed by venesection and 
other remedies. And he might have found many similar cases 
in practice. Therefore, I again say, remove the general 



84 LECTURE VI. 

symptoms, and you will remove the local affections connected 
with them ; but not vice versa, as he himself by this very case 
shows. For in this case, although the local disease was re- 
moved, the fever was not cured, but proceeded in its course 
even to the typhoid t} 7 pe. The doctrine I contend for, is far- 
ther confirmed by Dr. Fordyce's own observation, see p. 25, 
that general fever disappears and is entirely cured by the ap- 
pearance of local disease ; — whereas, upon his principle, the 
general fever should be increased instead of being diminished. 
But the contrary is the case. The general fever is very ge- 
nerally lessened by such local irritation, except for the time 
that such cause of irritation may be applied — during the ac- 
tion of a blister in a very sensitive system, the excitement is 
frequently very much augmented, but subsides in a short time. 
In like manner the local inflammation produced by mercury 
upon the salivary glands, frequently converts a general into a 
local disease. We observe the same fact upon the eruption 
of small-pox, measles, and chicken-pox, that the fever subsides 
upon the eruption taking place. So in like manner when erup- 
tions spontaneously take place in diseases not of an eruptive 
character, the same relief is afforded. I know a young 
woman in whom an eruption appeared on the limbs, in all 
respects resembling the small-pox, as the attendant upon acute 
rheumatism, affording relief to the general symptoms. An- 
other case occurred to me in a young child, in which an 
eruption appeared in the progress of a remitting fever. Erup- 
tions of this nature occur frequently in various parts of the 
body, and generally afford relief. They appear about the 
mouth, the lips, the nose — from their salutary nature they are 
hence called critical eruptions. Not from any peculiar virus 
or humour that is thus discharged, as was formerly supposed 
to be the case, (my views of the humoral pathology, I trust, 
do not extend to this ridiculous extreme !) but from the local 
irritation they produce, translating the general irritation from 
the blood-vessels and other parts of the system. Upon the 
same principle, blisters remove instead of increasing general 
fever, and are accordingly oftentimes prescribed for this very 
purpose, and with the best effects. I therefore am inclined to 
believe, that synocha will beget the local phlegmasia?, but that 






OF FEVERS IN GENERAL. 85 

the phlegmasia? are not, as Fordyce and others suppose, the 
primary diseases, at least generally speaking. 

At the same time, however, it is well known that local in- 
flammation will sometimes produce general fever, especially 
when seated in very sensible parts of the body and in habits of 
great irritability of nerve, as in females and in children. A 
wound, a surgical operation, a blister, teething, generally pro- 
duce fever. But it does not follow from this, that the phleg- 
masiae are in general the primary diseases, because they may 
be so in some instances, and are so under peculiar circum- 
stances. The physician of the Fever Institution, (see art. 
Fever. Rees,) observes, that in the advanced stage of fever, 
" inflammatory congestions are of not unfrequent occurrence, 
as in the stomach, lungs, intestines, and other organs," as al- 
ready noticed by Riverius, who also has remarked, in most 
distinct terms, that we ought to recollect that all those fevers 
w T ith which local inflammation is conjoined, are not sympto- 
matic, but often idiopathic, and that the inflammation super- 
venes, not being the cause, but as the consequence of the fever, 
— " qua? febrem istam non afficit sed illi potius succedanea est." 
He adds, " we frequently observe in practice, that patients 
labour under continued fever for a day or two before pain of 
the side and other symptoms of pleurisy appear ; thus also 
many persons, on the third or fourth day of fever, fall into in- 
flammation of the brain, &c, " sic nobis frequenter in usu 
practico videre licet asgrotantes, ab initio febre continua labo- 
rantes per unam aut alteram diem, antequam dolor lateris et 
alia pleuritidis signa appereant ; sic multi tertia vel quarta 
febris die in phrenitidem incidunt," &c. Riv. Prax. Med. lib. 
xvii. cap. 1. 

Speaking of pneumonia, Dr. Cullen observes that pyrexia is 
frequently formed for some hours before the local symptoms 
become considerable, and particularly before the pain is 
felt. And Boerhaave has justly remarked, vol. v. p. 4 — that 
pleurisy is rarely observed without a fever preceding it. So of 
the phlegmasia? in general. 

The second stage of fever now appears — no vis medicatrix 
is necessary to account for the phenomena which follow those 
of the first stage — no previous cold to beget the heat which 
succeeds. Attention to those symptoms will teach us that 



86 LECTURE VI. 

there is but one continued, direct irritation, from the beginning 
to the end of fever, whatever may be its source. True — 
the spasmodic constriction of the smaller arteries, and espe- 
cially of the exhalents, must necessarily, as I have already 
observed, accumulate the blood in the heart and larger ves- 
sels, including those of the brain, as well as of the chest. 
And this accumulation necessarily proves an additional stimu- 
lus in producing the excitement that succeeds, thereby adding 
to the fever ; but which fever, as w r e have seen, already exists. 
The cold stage doubtless must be considered as an additional 
source of excitement or irritation. We see this frequently ex- 
emplified. We see it in a person immersed in a cold bath — he 
generally experiences soon after a temporary degree even of 
febrile heat — the hands and face after exposure to cold, glow 
w r ith the increased action that succeeds. — And if the cold stage 
be induced by cold, such cold of itself becomes in some in- 
stances, even a direct source of irritation ; I mean to say, that 
it is a direct stimulus — there is no truth in medicine in my 
opinion better established, that is, if it is the property of a sti- 
mulus to excite or to increase sensation and motion, than 
that cold is a direct stimulant or excitant. That a current of 
cold air will produce a glow on the cheek by exciting the 
action of the arteries, I think you will not dispute ; nor I be- 
lieve will you question the fact, that a lump of ice or a snow- 
ball, applied to the sensible parts of the body, will awaken a 
person from a sound sleep. Immersing the hand of a person 
sleeping in cold water, we know to have the effect of exciting 
even the distant bladder to contraction. 

To return to our subject. — In consequence of the irritation 
so applied, the circulation accordingly becomes increased, and 
the pulse quickened; the skin becomes hot, dry, and glowing 
with blood, except when local determinations take place to the 
viscera, as in enteritis, and prevent or counteract the circulation 
to the surface. The cheeks especially, from their great sensibi- 
lity, become florid during fever — the ears also show the same 
excitement — the eyes too become red — the serous vessels of the 
adnata being now enlarged from the impetus given to them, 
carry red blood instead of serum. At this time, hemorrhagies 
not unfrequently take place from the vessels of the nose, espe- 
cially if the fever proceeds from a cause operating on the fluids, 



OF FEVERS IN GENERAL. 87 

as typhus. I have my three children at this time, in this very 
situation. The hands and feet also become hot and flushed — 
that is, the most sensible parts of the body become loaded with 
blood. In this respect a local, as well as a general fever, may 
be said to exist. 

Sometimes, indeed, as before remarked, a local fever exists 
without a general febrile excitement, (as in the cases of White 
and Smith of Whitehall; enteritis is their disease, yet there is no 
pulse, or heat, or state of the tongue indicating their condition;) 
but this excitability of the system from local causes greatly de- 
pends on the constitutional sensibility of the nervous tempera- 
ment. In some persons a common bile or whitlow, will beget 
a violent fever of the whole system. 

Besides this excitement in the blood-vesse|s during the second 
stage of fever, the respiration also becomes harried and anxious, 
in proportion as the blood is more or less rapidly conveyed 
to the lungs. The heat of the body, too, is in correspond- 
ence with the rapidity and irregularities of the circulation. 
The natural standard, as before observed, ife 98° of Fah. or 
rather 97^, to speak very accurately, the measure of heat 
being applied under the tongue. In this stage of fever it is 
increased even as high in some instances, according to For- 
dyce, as 105°. As I have already remarked, 110° or 112° have 
been noticed by authors, but their correctness becomes very 
questionable after the repeated, and, doubtless, accurate experi- 
ments of Drs. Fordyce and Currie. Perhaps the statement 
may be true of scarlatina, in which certainly the heat is 
more intense than in any other febrile affection. Dr. Willan 
says, that in that disease he has known it to be as high as 112°. 
Owing, too, to the partial determinations in the action of the 
blood-vessels, we also find the heat to show itself in some par- 
ticular parts of the body more than in others. Thus one ex- 
tremity of the patient is sometimes hot and of a florid colour, 
while another is cool and even pale. Senac states the same 
fact of a patient of his, who felt a coldness only in one arm. 
He also refers to another case, where ihe person had one side 
cold and the other hot, p. 25. As before observed, it is the 
effect of respiration to increase the heat of the body — the lungs 
are the fire-place ; but it is the province of the circulation to 
distribute that heat : hence, accordingly, we find it directed to 



88 LECTURE VI. 

particular parts, producing the effects which have been no- 
ticed. 

It is also worthy of remark, that the heat of the body, now 
increased and accumulated, becomes a great additional source 
of irritation and fever ; operating upon all the functions, vital, 
natural and animal. 

The disturbance of the brain and nervous system now be- 
comes increased by the additional irritation and excitement 
which has taken place, especially in the vascular system ; and 
as in the first stage, so in the second, we perceive its effects in 
all the faculties of the mind ; in the external senses, and the 
organs of motion — producing delirium— an increased confu- 
sion of thought — distressing dreams — insensibility to external 
objects — inability to distinguish them ; and in some instances, 
a total alienation of mind, amounting to mania. It is also ob- 
served, that when the patient dies in this stage of disease, the 
brain is frequently found to exhibit the evidences of great con- 
gestion and inflammation. 

The effects of the second stage are also manifest in the or- 
gans of secretion. The urine now becomes high-coloured, be- 
ing hurried through the kidneys half formed, almost partaking 
of the blood from whence it has been so recently separated. 
The same observation applies to the bilious secretion, which 
is also increased in quantity in consequence of a similar rapidity 
of circulation through the liver, as we see by the immense 
discharges of bile — and bile, too, just secreted — which often- 
times are observed to take place when vomiting or diarrhoea is 
excited. In like manner, the small vessels upon the surface, 
and indeed in every part of the system, become highly injected, 
for they are acted upon by a very powerful engine, the heart 
and its larger vessels. But although this impetus be given to 
the vascular system, the exhalents are not completely unlocked 
in this stage of fever. 

The absorbents partake of the same excitement that influ- 
ences the exhalent vessels. They also are quickened in their 
operation, as appears by the rapid diminution of the flesh and 
fat of the body, which is the consequence of fever, as we see 
exemplified in the hectic fever attendant upon phthisis, in which 
the very nails become curved around the fingers, such is the 
irritation attendant upon that disease. 






OF FEVERS IN GENERAL. 89 

We see the same loss of flesh in typhus fever, and in the fe- 
brile irritation of pregnancy. 

This increased excitement of the absorbent system also shows 
itself in the rapidity with which blisters are healed and disap- 
pear, owing not only to the strictured state of the exhalents, 
but to the excitement in the absorbents, which take up the effused 
fluid as fast as it is poured out Hence, too, the use of blisters 
in dropsy. 

The fluids of the intestines are in like manner rapidly carried 
away ; and this is probably the first cause of that costiveness 
which is so invariably the attendant upon fever. Hence the scy- 
bala and hardened fasces which are afterwards created. For this 
reason it is important to procure early evacuations in fevers, as 
we thereby guard against a great additional source of febrile 
excitement, arising from the materials so absorbed. Thus, too, 
we account for the dry and parched state of the tongue, as 
partly occasioned by the thinner fluids being taken away, as 
well as by diminished exhalation. Hence the secretions of the 
mouth become viscid and clammy, adhering to the surface 
from which they are secreted, as after the excitement of the 
system occasioned by too much wine. The discharge from the 
salivary glands, in the same manner, becomes thickened and 
adhesive. 

The fluid of anasarcous swellings accumulates after fevers 
have terminated, from want of energy in the absorbents ; but 
during the continuance of febrile action that fluid is sensibly 
diminished. Hence it is that febrile commotion, in whatever 
way excited, in many instances proves a cure for dropsy. 
Hence, too, the most active means that are prescribed in passive 
dropsy are such as produce a powerfully stimulant effect and 
excitement in the vascular system — mercury and squills — 
cantharides — horse-radish — mustard, and other stimulating 
ingredients, composing the fashionable diuretic decoctions. 
This accumulation in the blood-vessels makes evacuations more 
necessary, for by the neglect of them fever is aggravated, more 
especially by the reabsorption of the foul materials from the 
bowels. Not that it is necessary that such evacuations should 
be by venesection, but by the natural excretions of the body. 
Therefore not only retention of the noxious matters ordinarily 
evacuated, adds to the malignancy of fever, but an increase of 
9 



90 



LECTURE VI. 



foul materials in the blood-vessels, carried thither from the in- 
testines and other sources by the absorbents. 

We should therefore also be prepared to expect from violent 
fever, or fever long continued, a vitiated state of the mass of 
circulating fluids, both from those materials which are retained 
as well as those which are absorbed from the intestinal canal 
and other sources. These various vessels of the system, having 
their action continued a certain time, at length the body be- 
comes relaxed either by a remission or abatement, or by a 
total intermission of the symptoms of the disease, depending 
on the causes creating the irritation and the duration of those 
causes. In consequence of this general relaxation, ihe vessels 
on the external surface of the body become more patulous — 
the spasm, or stricture, or convulsion — call it what you please, 
ceases to exist, and the fluids are again discharged by the ex- 
halents in the form of sweat. Hence this stage of fever is 
denominated the third or sweating stage of fever. This too 
is to be considered as the effect of indirect debility, as opposed 
to that which is the direct effect of weakness, as occurs in the 
last stage of fever or during convalescence. 

The sweating stage may take place spontaneously, or it is 
the effect of art employed to relax and unlock the vessels of our 
system. When this stage has arrived, it displays itself in all 
the secretions and excretions — the excreting vessels of the 
tongue, mouth, fauces, and membrane lining the nose, all pour 
forth from their surfaces the fluids that had been pent up. 
Accordingly such discharges indicate a favourable change in 
the character of the complaint, and are an evidence that the 
irritation of the disease is subsiding. 

In like manner the excretion from the lungs is restored by 
this general solution of fever, as we see in phthisis to take 
place at the termination of the paroxysms of the hectic form 
of fever attendant upon that disease: and in ordinary pneu- 
monia, the same discharge by expectoration denotes the abate- 
ment of the general fever, as well as of the local inflammation, 
and hence constitutes one of the most favourable symptoms 
that can occur in pleurisy or peripneumony. The skin too, in 
the sweating stage of fever, changes its temperature not only 
as the effect of a diminished circulation at this period of fever, 
but as the consequence of evaporation and the absorption of 



OF FEVERS IN GENERAL. 91 

caloric by the conversion that takes place of the fluid discharg- 
ing from the surface into vapour. The skin, I may remark, 
generally manifests this favourable change first about the fore- 
head, and thence it becomes apparent over the other parts of 
the body. 

In the excretion from the kidneys an analogous degree of 
relaxation is apparent — the urine, instead of being pale as in 
the commencement of fever, or of a high colour as in the 
second stage, now deposits a large sediment, and is of more 
consistence : — this sediment consists of the earthy and saline 
materials of the blood, which the emulgents and their exhaling 
terminations permit readily to pass in this relaxed condition of 
the system. This sediment, from its resemblance to brick-dust 
in its colour and character, is hence denominated the brick- 
dust or lateritious sediment, so called from later — lateris, a 
brick. After the fever of gout and other diseases attendant 
upon a full habit of body, this deposite is uniformly observed to 
be very abundant. 

The discharge of bile from the liver, and of serous fluids 
into the intestinal canal, is in like manner restored, as we infer 
from the liquid stools and the bilious colour of them that some- 
times take place in this stage of fever. Indeed, in some in- 
stances diarrhoea takes place at this period. 

The uterus too experiences a degree of relaxation corre- 
spondent with the general condition of the system. The ves- 
sels of that viscus, which were surcharged in the second stage, 
now empty themselves by profuse menstruation — fluor albus 
reappears if it had been suspended — the lochia if suppressed 
are again restored. In some cases such is the determination 
to the uterine organs by fever, that the discharge amounts to 
haemorrhage. Even clots I have known discharged under such 
circumstances, and from a person too, whose womb had never 
been called upon to perform other duties — contrary to the 
opinion of those who consider the menstrual discharge to be 
a peculiar secretion, and not possessing the properties of blood. 
This doctrine of the discharge from the womb being sangui- 
neous I have long taught. I find it also to be the opinion of 
Sir E. Home, Cruikshank, Bichat, and others, as well as of 
Rhuysch, Hunter, and a host of others. The milk in a similar 



92 LECTURE VI. 

manner is restored, and ulcers again secrete their natural and 
healthy fluids. 

After the fever is terminated, if of short duration, the natu- 
ral feelings are all revived — the various appetites return, and in 
some instances acquire new vigour. The snuffer returns to his 
box, the smoker to his cigar, and the seminal secretion and 
appetite among others, is perhaps preternaturally acted upon 
by the now greater sensibility of system. The wife too, in this 
season of convalescence and returning vigour, is now some- 
times got with child that was never before pregnant. Such is 
the effect of the impulse that has been given to his system, that 
it becomes also a source of new impressions to the wife. 

To proceed. The functions are all restored, mental and 
bodily. The vital, natural, and animal functions, except 
where the system is much debilitated by the long continuance 
of febrile action, as in typhus and other continued fevers ; in 
which case the degree of debility is in proportion to the degree 
and duration of the existing irritation. But in this case, the 
debility not only shows itself in those parts of the system we 
have hitherto pointed out, it also displays itself in its effects 
upon the fluids of the system. 



93 



LECTURE VII. 



OF FEVERS IN GENERAL 



But fever not only operates, 1st, upon the nervous system; 
2d, it not only operates upon the muscular fibre, as it shows 
itself upon the larger muscles, upon the circulating, the exha- 
lent, and the absorbing vessels ; but it has also a third opera- 
tion: — it acts upon the fluids of the system as well as upon the 
solids, more especially when the fever is of considerable dura- 
tion and violence ; and that too, whatever may be the charac- 
ter of that fever, whether belonging to the class of febres, the 
phlegmasia?, or the cutanei. 

Allow me here to protest against the prevailing disposition 
among the medical teachers and practitioners of this day, and 
which has existed from the days of Dr. Cullen, to trace the 
seat, origin, and proximate cause of disease to the nervous 
system exclusively, totally disregarding the condition of the 
fluids and the vessels from whence the brain and nerves derive 
their powers, and upon which they constantly depend for the 
performance of their functions. 

When we look at the formation of the various parts of the 
body in the earliest stages of existence, we see the immediate 
dependence of vitality upon the globules of fluid circulating 
upon the part that may be the object of our examination. The 
fetus in the womb holds connexion with the mother, not 
through the medium of nerves or by sympathy, but by means 
of the fluids that circulate through an insensible tube, in which 
the anatomist, with all the aids he can derive from his glass or 
his knife, has not hitherto discovered the least evidence of a 
nervous fibril. Yet through this very conveyance do we see 
9* 



94 LECTURE VII. 

not only lie and health, but numerous diseases of the mother 
communicated to her offspring. 

In what does this change of the fluids consist ? I call it a 
putrid or putrescent state. — What is putrefaction ? I answer, 
it consists in a decomposition of the materials undergoing such 
process, and new chemical combinations or compounds taking 
the place of the materials so decomposed. 

In this process the solids lose their cohesion — the fluids lose 
their combination, and are divided into more minute molecules, 
from which again new chemical compounds are formed. 

In the ordinary process of putrefaction or decomposition too, 
there is usually an extrication of air towards the latter part of 
such process — that is, when such putrefactive process is com- 
pleted ; or in other words, some of the new products which are 
formed assume a gaseous or aeriform state. Not so, however, 
in all cases — for such extrication of air is not essential to the 
putrefactive process. Some say this extrication does not take 
place during life, and that the vital principle is the great anti- 
septic which counteracts the completion of the putrid stage : — 
but the vital principle being destroyed, surely that organization 
which is dependent upon it is destroyed. So it is during life : 
the vital principle being impaired, the organization is accord- 
ingly impaired. The vital principle partially destroyed, the 
organization becomes to the same extent destroyed or suspend- 
ed. But in some cases it may be renewed by the regeneration 
of parts so destroyed — as after gangrene or sphacelus. As far, 
therefore, as the vital principle may be destroyed or lose its 
controlling influence, so far putrefaction may take place, even 
in the living body. But this will especially be the case in those 
parts of the body in which the vital principle has the least in- 
fluence, — as in the fluids, which are certainly less dependent 
on the condition of the principle of life, than either the nervous 
or the moving fibre constituting the solids. Admit that the 
blood possesses vitality, (and some you know extend vitality to 
all the fluids of the body, not excepting the excretions,) I say, 
admit that the blood possesses the living principle, and it follows 
that in proportion as such power is impaired or destroyed, 
the fluids are liable to those changes they would undergo out 
of the body. But this tendency to the putrefactive process in 
any body, will also depend upon the number of articles making 



OF FEVERS IN GENERAL. 95 

up the compound. Out of the body, it is a fact established by 
chemists, that articles consisting but of one or two ingredients, 
as oils or resins, will not putrefy ; — that this process requires 
an aggregation of materials. In like manner, if such condi- 
tion exists in the fluids of the living body, — that is, that a great 
variety of materials be taken into the system, or those retained 
which are usually evacuated, or a new ferment be introduced, 
putrefaction may be expected when the vital principle is im- 
paired and loses its controlling influence over those fluids. 

It is of all things most strange, that Dr. Cullen and Dr. For- 
dyce, when describing the phenomena of fever, should have 
been so silent, at least so sparing in their observations on the 
effects which fever produces upon the fluids of the system ; — 
for they both, upon other occasions, were compelled to 
admit, though involuntarily, the changes which we contend 
for. As practical physicians and as candid men, they could 
not pass by those changes which the fluids undergo in dis- 
ease. Dr. Cullen in his Nosology, admits it in the following 
expression. See note to p. 72. " I suppose that the humours 
have a tendency to putridity in every typhus — but this only in 
different degrees — and a greater or. less tendency to putridity 
only varies, but does not change the species." " In omni typho 
humorum in putredinem proclivitatem adesse puto ; sed vario 
tantum gradu adest, ita ut major minorve putredo speciem 
variare, nequaquam mutare, potest." In his Materia Medica, 
vol. i. p. 62, 63, &c, in remarking upon the conversion of 
vegetable substances into the animal fluids, he says, that this 
conversion is best illustrated by the putrefactive process they 
undergo. 

Again; after the animal fluids are so formed or perfected, he 
observes, " they do not long remain stationary, but are conti- 
nually advancing towards a putrid state, and that these dege- 
nerated parts, i. e. putrescent materials, are constantly passing 
out of the body by the several excretions." p. 63. 

Speaking of the acrimony of the fluids, he says, " It is very 
possible it may be so ;" and adds, " that upon many occasions 
it certainly is so." p. 63. 

Again he remarks: " To conclude, I will not deny that the 
state of the fluids may have a share in distinguishing the dif- 
ferent states of the body both in health and in sickness — but at 



96 LECTURE VII. 

the same time I must maintain, that we know little of the 
manner in which it may have this effect : that our theory of 
the human fluids is still very incomplete and imperfect." p. 65. 
In his First Lines, (Rotheram's edition, p. 45,) he says: "From 
the dissolved state of the blood, as it presents itself when drawn 
out of the veins, or as it appears from the red blood being dis- 
posed to be effused and run off by various outlets, and from 
several other symptoms, I have no doubt, how much soever it 
has been disputed by ingenious men, that a putrescency of the 
fluids, to a certain degree, does really take place in many 
cases of fever." p. 45. Again, speaking of the causes of fever, 
he admits in p. 49, " that they arise from a putrescent matter; 
that their production is favoured, and their pow T er increased, by 
circumstances which favour putrefaction ; and furthermore, 
that they often prove putrefactive ferments with respect to the 
animal fluids." In his cure of fevers, his third indication, too, 
is expressly formed upon the existence of this state ; — for the 
object of it is " to obviate or correct the tendency of the fluids 
to putrefaction." The means of fulfilling this indication con- 
sists, — 1st, in avoiding the new application of putrid or putre- 
scent matter, — 2d, in evacuating the putrid or putrescent matter 
that may already be present in the body, — and 3d, in cor- 
recting what may remain by means of fixed air and other 
antiseptics, p. 88. See also his observations on scurvy, dia- 
betes, and hEematuria, pp. 328, 466, 573, et sequel. Yet Dr. 
Cullen in his preface, speaking of the doctrines of his great 
predecessor Hoffman, observes, that they were disfigured by 
intermixing the humoral pathology ! 

The system of Boerhaave, too, he pronounces on this ac- 
count to be fallacious, and apt to mislead — denominating the 
humoral pathology hypothetical, p. 17. But, as I have before 
observed to you, Dr. Cullen had powerful inducements to offer 
some new doctrines, whether ill or well founded. A strong 
current had been setting to Leyden. Boerhaave's merited ce- 
lebrity must be counteracted. To do this a new standard must 
be raised : and as he expressed himself to Dr. John Gregory, — 
" a tub must be thrown out to amuse the whale."* 

From what has been said, it is evident that he possessed a 

* See Gregory's Memorial. 



OF FEVERS IN GENERAL. 97 

perfect knowledge of the facts on this subject ; but it is no less 
certain that he wanted candour to promulgate them — because, 
forsooth, they are calculated to overthrow the favourite fabric 
that he had erected. In concluding his preface, after stating 
his intention of extending the doctrines of Hoffman, founded on 
the nervous and moving power, he also observes, " that he 
avoids the hypothetical doctrines of the humoral pathology, 
which disfigured his and all the other systems which had 
hitherto prevailed," and hopes to be excused for attempting a 
system which may appear new. p. 22. But Homer himself 
sometimes nods. 

Fordyce, who is no less inconsistent, you will also find 
falling into a similar error on this subject, in his description of 
fever. Yet in page 117, he has this expression: "True, it 
appears not uncommonly that very evident appearances of 
putrefaction take place in fevers which are very infectious ; yet 
in a great many fevers that are so, there are no appearances of 
putrefaction." Here the admission is given very grudgingly, 
(yet it is given,) that the putrid state may exist during life, 
though he does not specify the fluids which may undergo such 
putrid process. 

Armstrong, a bold writer, whose work on typhus fever, 
(third edition, p. 118,) has lately attracted the notice of the me- 
dical world as a work of great practical merit, thus expresses 
himself on the subject of the fluids as the seat of disease. 
" The humoral pathology no doubt abounded with absurdi- 
ties, yet I am fully satisfied that there are several diseases to 
which it might in some degree be justly extended ; and there- 
fore believe that its almost entire abandonment has been preju- 
dicial, by leading us from the investigation of various morbid 
states of the fluids, and of the means best fitted to correct 
them." And then he applies his remarks to haemorrhages and 
to petechias, as connected with a dissolved state of the blood. 
In like manner, some of the professors of the medical colleges 
of our own country have lately adopted the doctrines which 
have been taught in the New York school. I rejoice that 
these are, in general, the doctrines embodied in Dr. Eberle's 
excellent system of practice, which has now become the po- 
pular text-book in therapeutics.* 

* See also Gregory's Practice, with Notes by Drs. Potter and Calhoun, 



98 LECTURE VII. 

What, then, are the evidences of such condition of body exist- 
ing in fever ? 

The fluids of the body become changed from their healthy 
state, — 1st, by the causes of the disease. Fever occurs in such 
situations as are peculiarly favourable to such vitiated state of 
the fluids, as on ship-board, in hospitals, in camps, jails, &c, 
where the air becomes putrid and often si ve. Fever has been 
produced by putrid animal substances, — as the putrid whale in 
Holland, spoken of by Forestus. Parasus, in his Tract de 
Peste, cap. iii., observes also, that in his time the same thing 
took place on the coast of Tuscany. Septic effluvia, from 
putrid animal bodies, constitute the chief causes of putrid 
fevers. Sir John Pringle mentions a fever of this kind in the 
camp hospital, which was caused by a person lying in one of 
the wards with a mortified limb, at a time when the weather 
was very hot, and the place very close and badly ventilated. 
He mentions the fact also of his having known a dysentery 
(which is nothing more nor less than a fever, and often a very 
putrid one too,) to be occasioned by experiments on putrid 
blood. 

A fever of a most putrid sort was engendered from the pu- 
trefaction of cattle in the island of Nevis, from hides, &c, 
affecting the crew of a French ship, producing in the sick 
all those symptoms which are usually considered as indica- 
tive of such deranged or putrescent condition of the system, 
such as hsemorrhagies, purple spots, and carbuncles. Fevers 
are also recorded by Sir John Pringle, as the effects of the 
state of the air, induced by the putrefaction of dead bodies re- 
maining unburied on the field of battle. See Pringle's Dis. of 
the Army, p. 321. 

To these he adds, that the decomposition of vegetable sub- 
stances producing miasma, also gives rise to intermitting and 
remitting fevers, the last of which especially frequently run on 
into the typhoid type of fever; while others arise from ferments 
of a contagious character, introduced either by exposure to 
the diseased body or by art — as small-pox, measles, plague, 
and even the yellow fever. 

And in other instances again, we see fevers generated from 
the very condition of our system, independently of a materia 
ab extra — traceable to colluvies in the intestinal canal, the 



OF FEVERS IN GENERAL. 99 

effect of the excessive use of fish and other forms of animal 
diet — from putrid provisions, or from the contents of the bowels 
being rendered more than usually offensive and acrid from ne- 
glect — from the influence of season — change of climate, or 
other cause. Dysentery is thus not unfrequently lighted up in 
the individual, and afterwards, like typhus or yellow fever, 
assuming a contagious character, becomes communicable to 
others in a similar frame of body. 

2dly. The fluids of the body become changed from their 
natural and healthy state by the retention of those materials 
which are, when in health, ordinarily passed off by the skin, 
the lungs, the kidneys, and the bowels. The nature of those 
materials, and their peculiar qualities, will be noticed in an- 
other place. 

3dly. The fluids become changed by the absorption of the 
materials contained in the bowels, and these become more vi- 
tiated by the fermentative process which takes place in the 
stomach and small intestines when diseased, viz. the acetous 
fermentation ; and by the putrefactive fermentation of those 
contents that succeed in the lower tract of the intestinal tube, 
more especially in hot climates and in hot seasons of the year. 
By neglecting to evacuate the bowels in the first stage of fevers, 
practitioners not only lose the advantage of removing an ag- 
gravating cause of fever, but they absolutely protract it into a 
very tedious disease, that otherwise would have been little more 
than an ephemera : — and frequently too they thereby convert a 
simple fever into one of a malignant character. 

4thly. The fluids become changed by the reabsorption of 
the secreted fluids of the system ; at the same time, perhaps, 
that the whole of those secreted fluids had already undergone 
some change, previously to their secretion, by the morbid con- 
dition of the system existing in fever, as we see to take place in 
the ulcerated surface, as in the bowels, and in the quality and 
properties of the urine, all of which vary according to the state 
of body at the time of such secretion. 

The gelatin, the albumen, the fat, the saline materials of the 
body may be, and are probably thus reabsorbed, and contribute 
to those changes which are manifested in the circulating mass. 
Hence it is, that we see the blood in fevers exhibiting the buffy 
coat, that too of various characters ; and frequently too in the 



100 LECTURE VII. 

last stage of fevers, but not in the first. See Rush on Yellow 
Fever. Hence it happens, that in pregnancy the blood usually 
exhibits the buffy coat, owing probably to the absorption of 
the fat and other materials that are taken up, and produce the 
irritation so characteristic of the pregnant state. 

I may here just remark, that it is favourable to this explana- 
tion, that the buffy coat consists of this compound, that it 
putrefies some hours sooner than the other parts of the blood, 
as has been ascertained by repeated experiments made by Sir 
John Pringle, as you will see in the valuable appendix to his 
work on the Diseases of the Army, p. 75. I shall notice this 
subject upon another occasion. 

5thly. When diseases of this character occur, the body is 
under circumstances peculiarly favourable to such putrefactive 
process. The greater heat of climate and season in which 
such diseases are most prevalent, and the increased tempera- 
ture of the body itself in fever, are calculated to favour this 
change. 

What are the evidences we derive from the phenomena the 
body exhibits under such circumstances 1 

The streams depend upon the fountain. If the source be 
pure, so are the streams ; but if the former be foul, so also will 
be the latter. The fluids manifest these changes in the excre- 
tions of the system. 

As, 1st. In the urine, which becomes turbid, and oftentimes 
muddy, like beer. In some instances, again, it is bloody, re- 
sembling coffee-grounds. " I have seen," says Dr. Huxham, 
" several times the urine rendered almost quite black, de- 
positing an immense quantity of matter, nearly of the colour 
of coffee-grounds." Similar cases of black urine may be found 
in the books. — Treatise on Fevers, p. 38. In other cases, 
again, the urine is foetid, and so acrid that it affects the blad- 
der itself, exciting it to frequent evacuations. When you look 
at its saline ingredients, which are now so readily discharged, 
you are not surprised at the irritation it excites in the bladder. 

2d. The intestinal discharges show this condition of the fluids. 
In this state of body the discharges from the bowels are fre- 
quently frothy, like yeast, thereby indicating the fermenting or 
putrefactive process. The materials, too, evacuated, are highly 
offensive and acrid, exciting the bowels even to tenesmus and 



OF FEVERS IN GENERAL. 101 

diarrhoea, a frequent occurrence in fevers of the typhoid cha- 
racter. 

3d. The lungs, too, emit a peculiar effluvium, in fever, 
which is sometimes highly offensive, particularly in typhus; and 
indeed I may say, in the advanced stage of most fevers. It is 
to the acrid quality of the excretions from the surface of the 
lungs, in typhus fever, that we see that disease so uniformly at- 
tended with coughing. The tongue and the teeth also display 
this condition of the humours. The tongue is covered with a 
slimy, dirty, blackish matter. The gums are, in like manner, 
loaded with foul sordes, like that on the teeth. The lips par- 
take of it ; i. e. the secretions which take place about those parts 
are changed from their original and healthy state, analogous to 
similar changes in the other excretory organs of the body. A 
new and peculiar set of glands, situated in the gums, have re- 
cently been discovered to be the source of those peculiar secre- 
tions constituting the tartar on the teeth. The secretion from 
them no doubt adds to the offensiveness of the breath under 
these circumstances. At the same time, however, let me 
remark, that these symptoms are also attended with an impaired 
state of the vital powers in other respects, manifesting itself 
by hemorrhages, great depression of spirits, sighing, subsultus 
tendinum, &c. 

4th. The skin also excretes an offensive discharge. Instead 
of the natural smell of the perspirable matter, its smell is simi- 
lar to that of urine ; at the same time that it is exceedingly 
acrid and irritating to the surface, and frequently attended with 
petechias and vibices.* 

" Frequently," says Armstrong, " they not only arise from h> 
creased arterial action, or from relaxation of the extreme ves- 
sels, but oftentimes from a dissolved state of the blood, which 
undoubtedly occurs in the last stage of many fevers," He far- 
thermore subjoins, that " petechias, from increased action, are of 
a bright red colour — from relaxation, generally of a darkish 
brow# From a dissolved state of the blood, they have an inky 
appearance, always accompanied with effusions of very dark 
blood from other parts of the body, as the nose, bladder, or in- 



* See Richerand's Observations on Urinous Fever. See Armstrong on Ty- 
phus, p. 119. 

10 



102 



LECTURE VII. 



testines." p. 119. Indeed he believes, from repeated reflection, 
that the cause of death is some peculiar change in the blood 
itself, rendering it unfit for the purposes of vitality, p. 117-18. 

" Sometimes," says that minute, precise observer, Pringle, 
p. 313, " petechias are not seen till after death, i. e. after a still 
more complete decomposition ; but they are also frequent in 
the advanced stage of fever. The complaints attendant upon 
miliary fever are in this way produced," 

In the last stage of typhus, yellow fever, dysentery, and 
plague, these evidences of such change in the system are fre- 
quently met with. The eruptions, the blotches, and ecchymoma, 
of scurvy ; the hemorrhages from the nose, gums, lips, ears, 
bow T els and kidneys; the sphacelus from blisters, ulcers, and 
ichorous abscesses, all which occur in the advanced stages of 
fever, (as recorded by Lind, Pringle, and others,) are in this 
way only to be accounted for. The doctrines of Hoffman, 
Cullen, Brown, and others, who look exclusively to the nervous 
system for their principles of pathology, are very insufficient 
and unsatisfactory on this subject. 

The putrid, offensive sweats, and the cadaverous smell of the 
whole body, are also indicative of this putrescent condition of 
body. The colour of the skin is changed even during life, in the 
same manner as we observe to take place after death ; i. e. what 
occurs after the total extinction of the vital principle, to a ma- 
nifest degree, takes place during its partial extinction in the 
state approaching dissolution. After death from yellow fever, 
or from the bilious remitting, and in some instances from typhus 
fever, the body becomes yellow, and of a brownish, tawny hue. 
A similar change is apparent in the advanced stage of those 
fevers, and announces their fatal termination. In like manner 
the skin changes its colour by poisons introduced into the sys- 
tem ; such as laurel water, and the bite of a serpent, particu- 
larly about the parts bitten, as stated by Huxham. Some sup- 
pose the yellow colour that appears, to be produced by bile. 
This resort is not necessary. We see in dropsy, and especially 
in hydrocele, the serum effused to be frequently of the same 
yellow colour, when the liver has not manifested the least 
disease. Nor does the general aspect of the body exhibit 
the peculiar appearance of bile in those very cases in which 
such yellow serous effusions may have taken place. I some- 



OP FEVERS IN GENERAL. 103 

time since drew off from the vaginal sack, in a case of hy- 
drocele, nearly a pint of serous fluid, as yellow as fresh bile, 
yet the patient was otherwise in health. Dr. Warren, in 
his account of the yellow fever of Barbadoes, offers the best 
explanation of the change of colour that takes place in that 
disease. He accounts for it as dependent on the state of 
the fluids, and especially of the serum, which becomes altered 
in its properties, as the effects of the poison in impairing or de- 
stroying the vital principle that he supposes to exist in the fluids 
of the system ; analogous to the changes which the blood un- 
dergoes when effused or extra va sated, when it is out of the 
reach of the vital principle, as in a part that has been bruised ; 
or as we see it in an ecchymoma after venesection, or in the 
analogous effusions under the skin, attendant upon scurvy, in 
which a similar yellowish colour of the part is produced. We 
have a familiar example of the same appearance in a bruise of 
the eye, vulgarly called a black eye. The small vessels are 
broken, and the blood diffuses itself throughout the whole loose 
texture of the eyelids that are affected. 

Sir J. Pringle, in his Experiments upon the serum, Ap- 
pendix, p. 79, observes : " We are not always to ascribe this to 
inflammation, but to a solution of some of the red globules, 
mixed with the serum; for the serum is tinged with a small 
quantity of red blood when putrefied." In the very sanguine 
complexion, the skin is yellow ; in the dark, swarthy sailor, the 
red disappearing, the body assumes a dark nut-brown. It is 
not improbable, too, that the numerous sebaceous glands of the 
skin may have their secretions changed, which may aid in pro- 
ducing those changes of colour which the skin undergoes from 
febrile disease. The appearances after death, we know, in- 
stantly bespeak this change of the system. After death from 
fevers, that have been of long continuance, and have been at- 
tended with the malignant symptoms referred to, a rapid de- 
composition immediately ensues — much more so than after 
death from any other diseases. This change, this decomposi- 
tion or putrefactive process, I assert, must necessarily have 
begun before death But where do these evidences of dissolu- 
tion or decomposition first appear? I answer, in those parts 
of the body where fluids abound, viz. the brain, the eyes, nose, 
mouth, throat, abdomen, stomach, intestines, uterine organs, 



104 LECTURE VII. 

&c. This fact is observable in every dissecting-room. It was 
long since noticed and recorded by Dr. Hunter and others, as 
you will perceive upon consulting the appendix to the work of 
Sir John Pringle, in which you will find Dr. William Hunter's 
letter to Sir John Pringle, stating his observations made in the 
dissecting-room. — I add, it is in consequence of this rapid de- 
composition in the more fluid parts of the body, that anatomists, 
in dissecting the body, always begin with the brain, as decom- 
position soon takes place there, rendering it soft, destroying its 
texture, and confounding the various organs and tissues of which 
it is composed. They next proceed to the abdomen, and so on 
to the other cavities, w r here fluids abound ; and in the fluids, as 
before observed, the putrefactive process takes place more ra- 
pidly than it does in the relatively solid muscular fibre, which 
for many weeks remains unaltered, for the anatomist to pursue 
his dissections and demonstrations. 

But appearances, before death, no less indicate the com- 
mencement of the decomposition or putrefactive process, than 
that we observe so instantaneously to follow dissolution. The 
same state which has been described as the attendant upon the 
total extinction of life, is no less apparent before death, viz. the 
distended state of the abdomen, constituting tympanites.* The 
blotches on the belly, the offensive effluvia from the excretions, 
the cadaverous smell of the body, all indicate the same condi- 
tion that succeeds to the total extinction of life. In the case of 
a lady who died of scarlet fever, six months advanced in preg- 
nancy, there was, during life, tympanites ; and an offensive, 
cadaverous smell, and discolourations of the belly took place 
before death. She, herself, became conscious of the cadave- 
rous odour emitted from her own person ; for in this case the 
intellectual faculties and the senses were relatively undisturbed. 
In fifteen minutes after death the air of the room, and indeed 
of the adjoining apartments, became so intolerably offensive, 
that it was necessary to employ artificial means to purify the 
atmosphere, as recommended by Guyton de Morveau and 



* This distention of the belly is doubtless owing to the extrication of air from 
tlie decomposition of the fluids contained in the cavity of the belly, as well as 
those more immediately contained in the intestinal canal, and which we see so 
sensibly to increase immediately afler death. 



Or FEVERS IN GENERAL. 105 

Carmichael Smyth. In such cases, after death, the body is 
only to be preserved by artificial means, as immersing it in 
spirits, enclosing it in a tarred sheet, covering it in oil, or wash- 
ing it with the acetous or pyroligneous acid, the application of 
powdered charcoal, covering it with ice, or other means of con- 
trolling decomposition. Another evidence of such decomposition 
or putrefaction is derived from the fact noticed by Baron Percy, 
(see Journal of Science and the Arts, No. 23, p. 180,) that wounds 
in a malignant state have been known to manifest the same 
phosphorescent appearance, the same emission of light, that is 
known to take place from organized bodies when putrefaction 
takes place, as from putrid meat. But these are not all ; many 
other cases I have witnessed, in which this tympanites and 
change of colour took place. In ordinary cases we see the 
pulse to cease in the extremities, which become cold and rela- 
tively dead. Blistered surfaces, too, evince the loss of the vital 
principle, by the dark and black appearance which they fre- 
quently assume. Ulcerations, from whatever cause, exhibit, at 
this stage of disease, the same change. Even before death, 
and in cases, too, where the patient recovers, it is not unusual 
to observe this partial loss of the vital principle, when at least 
its operations are suspended. It ceases to have control over 
the extremities of the body ; the pulse ceases ; the hair drops 
out; the feet become insensible, and relatively dead, and per- 
haps remain so for weeks after general recovery. 

The remedies that are necessary to counteract this vitiated 
state of body bespeak its putrid condition. Stimulants, tonics, 
but especially that class of remedies denominated antiseptics, 
are in a peculiar manner called for in this condition of the sys- 
tem. We use acids, fixed air in yeast, (see Dobson on Fixed 
Air,) sudorifics, serpentaria, and particularly the acescent ve- 
getables — and such means only can restore the body to its natu- 
ral healthy state. (See an excellent note on the subject of the 
fluids in Lewis's Translation of Cullen's Nosology, p. 147, 
art. Tabes. Cabanis, p. 130.) 



10* 



100 



LECTURE VIII. 



OF FEVERS IN GENERAL, AND THE EVIDENCES OF A VITIATED 
CONDITION OT THE FLUIDS. 



But we are not limited to the facts which have been enu- 
merated. We have others that furnish the evidence of such a 
putrescent state of the body actually existing — proofs that the 
blood itself circulating in our vessels, undergoes a change ap- 
proaching to this process, as well as the fluids secreted from it. 
Fernelius, one of the most respectable authorities in medi- 
cine, (see Cabanis, p. 130,) and who is always spoken of as a 
philosopher as well as a physician, and in terms of the highest 
approbation, in his work on Fever, chap, vi., expressly states, 
that the blood drawn in putrid fevers (for the ancients always 
divided fevers into putrid and non-putrid,) is not only foetid, 
but that it has arrived at that condition that it will not coagu- 
late, its fibrous texture being destroyed by decomposition or 
putrefaction. — " Sanguis qui per febres putridas detrahitur ssepe 
animadvertitur non solum fostidus et graveolens, sed et putridus ; 
adeo ut nee sibi coheerere nee concrescere queat, omnibus sci- 
licet ejus fibris putredini consumptis." Fernel. de Febr. cap. v. 

Morton, another celebrated physician, in his Pyretologia, 
states the case of the blood drawn from a female in malignant 
fever, being so offensive that it not only greatly annoyed the ope- 
rator, but was perceptible to the bystanders. The same author 
(see Prolegomena, p. 26,) observes, that in petechial fever the 
blood when drawn emits a foetor as well as the urine. Swenc- 
kius (see Haematologia, p. 90,) also states, that in putrid dis- 
eases, and especially in plague, the blood is found in a putrid 
state. Pringle remarks, " that besides numberless observa- 



EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 107 

tions of the corruption of most of the secretions as well as 
the excretions in diseases, we have frequent instances of the 
tawny colour of the serum, the resolution of the crassamen- 
tum, and even of the offensive smell of the blood recently 
drawn." Huxham, in his work on fevers, (chap, v.) in a 
chapter expressly written on the dissolved and putrid state of 
the blood, states many facts corroborative of this condition 
existing even during life — not only as manifesting itself in the 
discharges which take place from the body, but by the sensible 
properties and changes wrought in the blood itself. See Cleg- 
horn, p. 101. 

In the " General Considerations" prefixed to Bichat's 
" General Anatomy," is the following passage :* " I cannot 
forbear relating a fact, which contradicts all that has been 
lately advanced relative to the incorruptibility of the blood in 
diseases. Engaged a short time ago in opening a body at the 
Hotel Dieu, with MM. Peborde, L'Herminier, and Courder, 
I found, instead of the black blood that is common to the 
abdomen, a sanious grayish fluid, which filled all the divi- 
sions of the splenic vein, the trunks of the vena porta and its 
hepatic branches, so that, on cutting the liver in slices, we 
could perceive, by the oozing out of this matter, the various 
ramifications of the vena porta and vena cava, which contained 
common blood. The body was so remarkable for its obesity, 
that I do not recollect ever having seen one like it. This state 
of fluid certainly did not proceed from the effects of dissolu- 
tion ; so that the blood must have been, while circulating, if 
not vitiated to this degree, at least very different from its natu- 
ral state, and absolutely decomposed." 

The reason why we do not so often meet with this state of 
the blood as might be expected, doubtless is, that we so rarely 
draw blood from the body in the advanced stage of fevers. 

Physiologists consider the blood not only to be kept from 
putrefaction by the vital principle, but also by its constant mo- 
tion ; as the constant movement of running water and the agi- 
tation of the sea preserve rivers and the ocean pure. Motion, 
in these last cases, certainly serves to exhale both from sea 
and river water its most putrid particles. 

* Vide p. 41. — London edition, 1824, 



108 LECTURE VIII. 

At the same time that its movements interrupt to a degree 
the fermentative process that otherwise would take' place; for 
rest is necessary to fermentation, and so far such motion con- 
trols its putrefaction ; but when it ceases to flow in the distant 
vessels, this preservative power is diminished or lost. 

So secretion and excretion convey out the noxious materials 
from our system, and new materials take their place : but when 
those noxious excretions are retained, and these new materials 
are withheld, the effects are very soon perceived. Dr. Lind 
remarks, that he has always observed that the Romish clergy, 
who are in the habit of frequent fasting, become scorbutic, and 
remarkable for a foetid and offensive breath. He asks, " Can 
we ascribe this sudden effect of fasting to a disorganization in 
the solids ? Is it not more consonant to the laws of the eco- 
nomy, that the blood, being deprived of regular supplies of 
mild and nutritious chyle, should be first affected by this loss, 
and that the solids suffer in a secondary way only ?" Lind on 
Scurvy, p. 328. But, independently of the fresh supplies of 
chyle, these secretions being stopped, the putrefactive process 
soon succeeds. So with the ocean itself — in calms of any du- 
ration, it soon becomes highly offensive, and its surface is 
covered with the results of such putrid process. After three 
days' calm in the month of August, 1794, I witnessed this fact 
on the Atlantic Ocean. The sea for miles around us was co- 
vered with a scum that became exceedingly offensive, (the heat 
at the same time being great,) and very soon after our whole 
crew and passengers became sick with typhus fever. A simi- 
lar fact I have met with either in Cook, Clark, or Humboldt, 
Silliman, or some other voyager equally respectable, though 
I cannot now verify the authority. The moderate motion of 
the sea, therefore, does not of itself prevent that process from 
taking place even in the waters of the ocean. 

So it goes on to a certain extent in the blood-vessels. We 
see fermentation, (for we have no better term by which to de- 
signate the assimilating process which takes place in fevers,) 
I say, we see fermentation in small-pox, in measles, in the 
yellow fever, in jail fever, and in plague, and indeed in all 
diseases arising from contagion. We even see this fermenta- 
tive or assimilating process in various parts of the body. We 
see it in the processes of secretion and assimilation going on 



EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 109 

in the intestines, in the lacteals, in the blood-vessels. We see 
it in all the secreting and excreting vessels. What are these 
but decompositions and new chemical combinations 1 Putre- 
faction is an analogous process. I know no distinction between 
fermentation and putrefaction. Indeed, fermentation is deno- 
minated in this stage the putrefactive fermentation, to distin- 
guish it from the first stages of the same process, the vinous 
and acetous fermentations. Sir John Pringle used to observe, 
w That from the Greeks down to the present time, medicine was 
a science in which there was a great deal of reasoning upon a 
small number of facts ;" and justly adds, " that in future, on 
the contrary, there ought to be little reasoning upon a great 
number of facts." Upon the subject before us, there has been 
a great deal of discussion, (especially since the fashionable re- 
jection of the humoral pathology,) but these speculations I 
trust, must yield to the numerous facts which we have now 
assembled, and which all lead irresistibly to the conclusion, that 
a putrescent state of the fluids occasionally takes place even in 
the living system. 

Such at least is the conclusion I draw from them. But 
whatever may be the speculations we indulge, however unsa- 
tisfactory may be our explanation of the phenomena which 
have been enumerated, the facts themselves can never be in- 
validated relative to such change, let that change be called by 
whatever name. And, as subservient to practice, they are all 
important ; for without giving attention to the use of those 
means that are peculiarly calculated to resist this putrescent 
or vitiated condition of the fluids, we shall prescribe in vain. 

Dr. Cullen, the great but inconsistent opponent of the humo- 
ral pathology, admits that the bark is of no importance in the 
cure of scurvy, — that this is not merely a disease of debility, 
but of a peculiar vice of the system, to be otherwise corrected. 
In like manner, in the cases related to you in my clinical lec- 
tures of the scurvy and scorbutic eruptions which prevailed in 
the state prison, we might have gone on to the end of time 
with mercury and sulphur, without curing the disease, which 
ripe acescent fruits and other vegetable antiseptics, immediately 
effected. So in fevers of the typhoid type. 

It is uniformly urged as an objection to this doctrine, that if 
putrefaction existed in the blood, air must be extricated, and 



110 LECTURE VIII. 

consequently the texture of the vessels must be immediately 
destroyed. Putrefaction, as I said before, is fermentation, i. e. 
decomposition, or a change in the compounds and new combi- 
nations formed out of the same materials. 

In the processes of chylification and the formation of blood — 
in the assimilation of that blood to the purposes for which it is 
destined, we have such decompositions and new compounds 
formed without the extrication of air. But we see actual fer- 
mentation or change go on without the extrication of air. We 
see it in every bottle of wine, however carefully it may be 
sealed, (for the ripening of wine is no other process.) And, as 
Walker observes, we see it in the living body in small-pox, the 
multiplication of which in the body he calls a fermentative 
process, and in which Dr. Cullen concurs. 

Dr. Cullen in his First Lines, (vol. v. p. 597,) says, " It is 
evident that the contagion of small-pox acts as a ferment with 
respect to the human fluids, and assimilates a great part of 
them to its own nature.'' Cruikshank, one of the most en- 
lightened of our profession, also expresses the same opinion 
still more amply. (See Dyckman's Pathology of the Human 
Fluids, p. 185.) This species of fermentation is hence called 
silent fermentation, as having some laws peculiar to itself; as 
opposed to that which takes place in the open air or under 
other circumstances. But, allowing for a moment that air 
should be extricated in the blood-vessels, I ask, must it neces- 
sarily prove fatal? I say yes, if it be suddenly introduced 
into the blood-vessels, and in large quantities. So of pus, and 
indeed water, in large quantities. Even blood itself in transfu- 
sion, if suddenly introduced, proves immediately fatal. See 
an excellent paper by John Hunter, on the inflammation of the 
veins after venesection, in the Chirurgical Transactions, vol. i. 
Yet pus taken gradually into the system by absorption, is not 
immediately fatal, and perhaps not so at all. But it produces 
a peculiar form of fever called hectic fever ; and this, I believe, 
is the only way in which hectic fever is ever formed. I have 
never seen a hectic fever but from this cause. Remember the 
peculiar characters of hectic fever. It is not every waste of 
the body from weakness, but much more, as its name imports. 
It comes from the Greek word «£/?, which signifies a habit. 



EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. Ill 

Some, by the by, contend that hectic fever is formed without 
the presence of pus in the blood-vessels ; and they will give 
you as an example a caries of the bone, or a diseased joint, as 
attended with such fever, and yet without pus. Is this so 1 Is 
there no absorption of matter 1 I ask what is a caries of the 
bone but an ulcer of the bone 1 And where is the ulcer with- 
out secretion? Where is the ulcer without matter? And what is 
this matter but pus 1 True, the pus of bone is one thing in ap- 
pearance, the pus of flesh is another — yet both are nevertheless 
pus, and will produce all the effects of pus in the blood-vessels. 
Although the muscular fibre of fish is different from that of 
other animals, they are muscular fibre; although, as the scrip- 
ture tells us, the flesh of fish is one, and the flesh of birds is 
another, they are nevertheless flesh. So the pus of bone may 
have some appearances differing from that of the soft parts ; it 
is nevertheless pus. To return from this digression. — The ex- 
periments of Redi, and other eminent naturalists, show that air, 
like pus, may be conveyed into the veins slowly and in small 
quantities, without killing the animal. " Pauco aere injecto 
neque necatis animalibus." — Redi, vol. iv. p. 223. See also 
Pringle, Ap. p. 89. 

But this part of the subject may now be put at rest, since the 
observations of Mr. Home and Mr. Bauer, lately published in 
the Philosophical Transactions, showing the presence of air 
circulating in our vessels, and that the very qualities of that air 
have been ascertained, viz. fixed air, given out in coagulation* 
p. 463. 

But we do not contend for absolute putrefaction in the living 
body, while influenced by, and under the control of, the vital 
principle ; or say that it proceeds to the same extent that takes 
place after death ; but that so far as the vital principle is de- 
stroyed in the part, or in the whole system, so far putrefaction 
may take place during the life of the body. 

But do we see this grade of putrefaction, this commence- 
ment of the process, exhibited by experiments out of the body 1 
Yes we do. — See Pringle's experiments on flesh and upon blood. 
Before air was extricated in such quantity as to be percepti- 
ble, putrefaction began. The specific gravity of the material, 
the subject of the experiments, was changed ; the substance 
floated before such air could at all be detected by the senses; 



112 LECTURE VIII. 

yet a separation, to a certain extent, had taken place between 
the integrant parts of the substance undergoing such change. 

Similar decomposition may certainly take place in the living 
body, especially in the blood and other fluids, in which there is 
less of the vital principle, and where it exercises less control 
than in the solids. And it is farther to be observed, that from the 
experiments of Sir John Pringle, and of Dr. Hales, (See Veg. 
Static, ch. vi.) that much more air is extricated from putrid flesh 
than from putrid blood. The same quantity of air, therefore, 
is not to be expected from such changes in the fluids as would 
be looked for from the decomposition of the solids ; the fluids 
would be much more advanced in the putrescent state before 
they exhibited this evidence of such change. 

But w T hile silent fermentation can exist in other bodies, so 
also may that silent form of putrefaction, that putrescent grade, 
take place in the less vital parts even of the living system ; for 
all the chemical changes which occur in the body are assuredly 
controlled, and more or less modified, by the influence of the 
vital principle. Hence, therefore, it is certainly possible that a 
degree of the putrefactive process may take place during life, 
in as far as the vital principle itself is impaired, and its con- 
trolling power diminished. It is even possible that putrefaction 
itself may have some peculiarities — some limits in the living 
body, which it has not after death, under different circum- 
stances. Without admitting this result in a certain extent, as 
before remarked, we cannot possibly in any way account for the 
rapid decomposition which so instantaneously takes place after 
dissolution, as well as many other facts which have been no- 
ticed. 

Whatever may be our reasonings or our speculations, our 
facts themselves must stand uncontradicted. We may cloud 
them in words, or obscure them by sophistry ; they are never- 
theless the same ; and so far the humoral pathology must be 
received. 

But fever, in the last stage of disease, is not confined to these 
effects upon the fluids ; the solids also become, in turn, affected 
by their reaction. As the heat that is accumulated by fever 
becomes in turn a new and additional source of excitement, so 
the fluids, being vitiated in the manner that has been stated, 
become a new source of irritation and of exhaustion to the 



EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 1 13 

nervous and moving fibre — a sort of secondary fever, as it 
may be called, ensues. 

In the last stage, the typhoid state of fever, now to be no- 
ticed, the solids, I observe, are in turn reacted upon by the 
fluids, which have become vitiated. Such vitiation is produced 
by long-continued action — whether the fever in which it occurs 
be induced by cold ; by marsh effluvia ; by human effluvia ; or 
the materies morbi of diseases acknowledged by all to be con- 
tagious, as small-pox, measles, scarlatina, &c. We occa- 
sionally see cases of pleurisy from cold, exhibiting a similar 
malignancy. 

Rheumatism, in 1797, prevailed in New York to a great de- 
gree, and exhibited a great tendency to assume the typhoid type, 
in which venesection was injurious. Analogous cases are no- 
ticed by Sydenham, as influenced by peculiarity of season, state 
of the air, &c. 

Intermittent fevers, from marsh effluvia, in some cases run 
into that type ; and are especially malignant on alternate days 
— particularly those fevers occurring in the heat of summer, or 
in hot climates — thence they readily become continued and 
contagious, as noticed by Cleghorn, in Minorca, and by Russel, 
in his history of Aleppo. See also Senac. And on the same 
account remittents still more frequently terminate in typhus, as 
they are a nearer approach to the uninterrupted or continued 
form of fever. Even hectic fever, I believe, would become so, 
if regular intermissions did not occur to counteract the putre- 
scent tendency, by the sweat and other natural secretions and 
excretions being restored. In small-pox too, that is, in natural 
small-pox, which is generally the confluent form of it, there is 
always a secondary fever, from the reabsorption of the matter 
from the surface ; and this secondary fever, very generally, as- 
sumes the typhoid type. Measles also, in some cases, exhibit 
the evidences of putrescency. — See Watson's account of what 
he denominates putrid measles, in the London Observations and 
Inquiries — see also Willan's Rubeola Nigra. 

I witnessed several cases of typhoid measles in 1795, in New 

York, particularly in a family that had recently arrived from 

the West Indies, and probably with their systems more or less 

influenced and changed by the heat of the climate they had 

11 



114 



LECTURE VIII. 



left. It assumed a malignancy which I have observed but once 
since that period. I saw another case in the hospital in 1819, 
during the prevalence of typhus in the same ward. 

In scarlatina this condition of body is also of very common 
occurrence. In a family in this city, it was a very fatal dis- 
ease ; and it will ever be so if active measures be not taken to 
guard against this condition of body, and attention be not paid 
to the different stages of that disease, which you will find very 
much neglected even by the best practical writers. Dr. Heber- 
den himself, distinguished as he is for his practical observations, 
does not appear to recognise these different stages. 

In like manner, the ferment of concentrated human effluvia 
produces this typhoid form of fever, and is propagated by con- 
tagion. This is perhaps the only idiopathic form of typhus 
fever ; the others being symptomatic of long-continued excite- 
ment. 

I call jail, camp, or ship fever, idiopathic, because the dis- 
ease has a tendency to assume that character, notwithstanding 
all the exertions; that may be made to counteract this tendency. 
The predisposition is in the previous state of the fluids. I call 
■the poison: or ft^iot communicated by jail and other fevers, of a 
'contagiousiinaiture, a ferment, because it acts as such upon the 
'circulating i fluids. That " a little leaven leaveneth the whole 
lump," is as true in fevers as in making bread, or in the 
conversion of acescent fluids into the acetous acid — and that 
upon the same principle of assimilation. That one spoiled her- 
ring will taint the whole cask, is well known to every house- 
wife or fish-monger ; hence the great care of the Dutch in their 
herring fisheries to salt down their fish as soon as they are 
taken. They never permit the sun to rise upon them. Sir 
John Pringle's experiments with an egg, a living body, illus- 
trates this principle very happily. The same assimilating pro- 
cess I believe to take place in small-pox, in syphilis, and other 
diseases which are universally admitted to be contagious dis- 
eases. It is called by Walker, the assimilating fermentation. 
The same process, I believe, takes place in fevers ; and that the 
■peculiar taint formed by the excretions of the system repro- 
duces in others precisely the same disease, whether it be dysen- 
tery, yellow fever, plague, ship or jail fever. 



EVIDENCES OF VITIATED CONDITION OF THE FLUIDS. 115 

Hewson, the celebrated anatomist, died of typhus fever, 
induced by a wound received in dissecting a diseased body : 
the poison conveyed proved a ferment and source of morbid 
excitement to the whole system. During the winter of 1827-8, 
a fatal and much to be lamented case, of a similar nature, 
occurred within these walls, in which such local irritation was 
followed by an excitement that appeared in every part of the 
system ; at first operating upon the stomach, intestines and 
brain ; and thence diffusing its deadly effects throughout the 
frame. Numerous cases of fatal fevers have been produced in 
London and Edinburgh by this cause, among the young men 
attending the dissecting rooms. But in some instances, such 
poison vents its force upon a single gland, producing perhaps a 
bubo in the axilla, as in the case of my own brother. 

We see, then, two distinct causes of this typhoid state of 
body. 1. A worn-out state of the excitement ; and, 2. A fer- 
ment introduced. But the first is of itself sufficient in fevers 
to induce this derangement -of the whole system, without the 
last, by wasting the nervous energy and that of the moving 
fibre ; and thence the impaired state of the functions of circu- 
lation and excretion which succeeds. 

I xlo not, however, mean that merely a long-continued action, 
if it did not operate by its effects on the secretions, would of 
itself create typhus ; (that alone would produce symptoms of 
simple debility, a worn-out state of the nervous system and the 
muscular fibre, as manifested in the impaired strength of the 
body ;) but that it also acts on those vessels of the system upon 
which the state of our fluids depends. I mean the secreting, 
excreting, and absorbent systems of vessels. 

This typhous state of body is accordingly sometimes mani- 
fested, as before observed, in pleurisy, or in an intermitting 
fever ; but in those fevers arising from contagion or putrid fer- 
ments, added to the materials already existing in our circulating 
fluids, typhus is more readily produced ; sooner manifests itself 
in the progress of the fever by depression, sighing, and other 
affections, denoting an impaired state of the nervous system ; 
and more rapidly proves fatal, as in yellow fever, plague, spot- 
ted fever, than it is when generated under the circumstances 
before stated. This vitiated state of the fluids, combined with 



116 LECTURE VIII. 

debility, constitutes the typhoid type of fever : hence then, we 
see two classes of symptoms manifested in cases of this nature. 
First, those which are ascribable to an exhausted state of the 
nervous and muscular powers ; and, secondly, those depending 
upon the condition of the circulating and the secreted fluids. 
So that this debility appears in all the functions of the system^ 
the vital, natural and animal 



117 



LECTURE IX. 



THE TYPHOID STATE OF FEVER 



We observed yesterday, the typhoid state of fever to be made 
up of two classes of symptoms. 

1st. Such as are referable to an exhausted state of the gene- 
ral excitement — that is, independently of any change in the 
condition of the fluids or of the system in any other respects. 

And, 2dly. Those symptoms which arise from a deranged 
state of the fluids, as manifesting themselves both in the circu- 
lating and secreted fluids. 

This impaired state of the nervous system shows itself in all 
the functions both of the mind and body. It appears in the 
imagination ; it discovers itself in an impaired state of the 
judgment ; in the reasoning faculty, and in the memory. We 
see it in the imagination or perception of things, which is ge- 
nerally false at this advanced period of fever. The sick man 
imagines things which have no existence. The external senses, 
too, are impaired. He sees supposed objects constantly before 
him. He now exhibits a perfect pseudoblepsis imaginaria, ana- 
logous to that, state of the brain which is induced by spirituous 
liquors ; or similar to that state of mind which is intoxicated 
by passion or deranged by the consciousness of crime or guilt; 
as Macbeth, when about to commit murder, sees the air- 
drawn dagger, which, in his eyes, is so palpable, that he draws 
it from its scabbard. 

In fever, sometimes, those objects appear to him in one shape 

— then in another ; — he sees men — flies, (hence called muses 

volitantes.) So strong is the impression that he catches at them 

— he rises up in bed, in pursuit of them ; in some instances his 

fears are excited, and he endeavours to fly from them. His 
11* 



118 LECTURE IX. 

eftrs are no less affected in the sense of hearing ; — in some in- 
stances the sensibility is so great that the patient is disturbed 
by the very pulsations of the arteries ; in other cases the nerves 
of the ear, like those of the eye, are acted upon by imaginary 
impressions, the effect of the creative power which they acquire 
in this diseased state of the nervous system — well denomi- 
nated paracusis imaginaria, similar to that sometimes attend- 
ant upon dyspepsia. In like manner, the patient, in fever, hears 
drums beating to battle — or a person calling him, — he hears 
the bell toll — he sees his coffin — they are about to take him off 
for burial — he springs up — gets out of bed — wishes to go out 
•^—conceits himself not at home — (he wants to go home ;) and, 
if not prevented, runs into the street, or leaps from a window. 
He is unconscious of his family and friends — talks incoherently 
— mutters to himself — is with great difficulty controlled — ten 
thousand thoughts rush upon his mind in rapid succession — 
every pulse almost brings with it a new impression ; so sensitive 
is the condition of his brain, with regard to internal impres- 
sions. Not so to external ones ; to these he is comparatively 
insensible; and sometimes altogether unconscious of what, is 
passing around him ; but by loud speaking he is roused from 
this reverie, and for a moment is perhaps consistent ; but his 
mind is instantly disturbed again by the same phantasms, and 
he relapses into the same maniacal delirium as before. During 
this condition of body, and which perhaps continues for seve- 
ral days and nights, especially if mismanaged by the physician* 
he is constantly watchful ; or if he sleeps, he is in continued 
agitation : you see it in every muscle of his body — his cheeks 
— his lips — -his eyes — (they are all in motion) — his extremities 
also are in continual change from place to place ; and each 
muscle in exercise. A subsultus tendinum, or an irregular ac- 
tion of the muscles, as in chorea, pervades his frame ; if he 
awakes, he awakes confused — or is roused by a distressing 
dream — or perhaps imagines himself upon a precipice, or fall- 
ing from a great height. The memory, too, like the other 
faculties of the mind, is also affected, not only during the con- 
tinuance of fever, but even long after recovery. This I expe- 
rienced after scarlatina, in 1801 — my memory was impaired 
for six weeks after my recovery. On that occasion I was 
obliged to carry a memorandum of my patients, and of my 



THE TYPHOID STATE OF FEVER. 119 

prescriptions for their complaints. In other fevers again, as in 
the plague and yellow fever, the animal functions, as they ap- 
pear in the senses and in the muscular organs, sometimes re- 
main undisturbed to the last of life. In those cases the disease 
appears to vent itself upon the fluids of the body; or upon 
some particular organ, as the stomach or liver. In all these 
cases the patients consider themselves well at the very moment 
that their graves are prepared for them, and the hearse is wait- 
ing at the door for their dissolution. This is not an imaginary 
picture, but drawn from the facts which have come within my 
own knowledge. For the most part, these walking cases, as 
they have been very properly called, are fatal cases. I have 
seen, however, two exceptions ; and strange to tell, both grog 
drinkers ; yet both recovered. The one was the late Mr. J. H. 
— he was thought by his physician, Dr. Tillary, to be dying — 
his skin was yellow — he had a violent hiccup, and was far 
advanced in the disease — he got hold of his can, and soon 
drowned the fever. Met by a friend, he cried out, " I have 
killed it — I have killed it." He was a man of fine talents, and 
of a finished education, received under Beattie and Campbell, in 
Scotland. But he became intemperate, and sunk so low as to be 
a wanderer in our streets. The second case was that of a Mr. 
T. I found him sitting on the floor, with a blanket about him, 
and his mug of stiff brandy and water at his side. He accosted 
me thus : " There is my physician, Doctor, I shall live or die 
by it." He too recovered. I lately treated a case of typhus 
fever upon the same principle — of preserving the excitement 
of the system by brandy. Finding that, in health, my patient 
had been in habits of indulgence in the use of spirituous drinks, 
the indication was apparent to adjust the degree of stimulus to 
the condition which the previous habit had produced. 

In other fevers, again, the patient is affected by stupor or 
coma, at this period of the disease, instead of the irritations of 
the brain which have been mentioned. For the most part, coma 
or stupor appears late in the disease. The jaw falls ; the mouth 
remains open ; and symptoms of apoplexy ensue. Stupor, how- 
ever, in this stage, does not arise from an active fulness of the 
vessels, but from a worn-out excitement of the brain, which in 
some cases shows its loss of power by this torpor, or from di- 
minished action in the absorbents, or in retarded circulation of 



120 LECTURE IX. 

the venous system of vessels ; and hence patients frequently 
recover without the usual consequence of apoplexy, from pres- 
sure produced by an overloaded state of the vessels, from 
increased arterial action of the brain — as Dr. Bard justly ob- 
serves, " They sleep away their disease." But, in some cases, 
this stupor appears very early in the disease, from accidental 
determinations to the brain, or effusion taking place from the 
exhalents. The brain, in such case, soon becomes so engorged, 
that if it is not instantly relieved, an apoplexy follows. This 
mode of attack constitutes the congestive typhus of authors. 
Frequently, in fevers, partial determinations of this sort take 
place, owing to peculiarity of temperament ; and perhaps ori- 
ginal make of brain, as well as the pursuits of the patient, when 
in health. Hence literary characters soon become delirious in 
fevers, whatever may be their type ; and in every stage of 
them, the first, as well as the last. With regard to delirium, 
too, it is important to distinguish between that which arises 
from the first or inflammatory stage of fever, and that which 
occurs in the advanced stage. This may generally be known 
by the duration of the disease — the evacuations the patient has 
undergone — the degree of abstinence which has been observed 
— the causes of the disease ; but more especially by the ac- 
companying symptoms, such as the state of the circulation, the 
pulse, heat, respiration, and the state of the secretions and ex- 
cretions. 

It is important to ascertain the character, nature and origin 
of the delirium, because this knowledge must be the guide of 
our practice. 

For example : — Delirium in the first stage, as it proceeds 
from an active current of blood to the brain, calls for one class 
of remedies, such as are calculated to diminish excitement. 
While that of the last, requires a treatment totally opposite ; to 
excite the system by tonics, and the most powerful and diffusi- 
ble stimuli. In this stage of the disease the pulse is small, fre- 
quent, and oftentimes irregular. The circulation being rapid, 
the respiration is also in proportion hurried and irregular, at- 
tended with frequent sighing and sense of oppression. The 
heat is also in correspondence with the quickened action of the 
heart and lungs. The blood, I told you, is the vehicle of heat 
* — but the fluids themselves are now changed in their condition ; 



THE TYPHOID STATE OF FEVER. 121 

you have not merely heat, but a modification of heat, de- 
rived probably from the quality of the fluids that convey it. It 
is accordingly intense, and of that peculiar sort that leaves an 
impression on the hand of the physician. The French call it 
" chaleur d'acrimonie." Wright calls it a biting heat. The 
same has been noticed by Huxham, Dr. Moore, and most prac- 
tical writers. Dr. Frank describes it as " acer, digitosque 
urens" comparing it to the impression produced by the sting- 
ing nettle, the urtica urens : — while others again, compare it, 
with more propriety, to the sensation excited by hartshorn ap- 
plied to the hand or other sensible parts of the body. This 
sensation appears to arise more from the peculiarly acrid nature 
of the discharges from the surface, in the advanced stage of 
fevers, than from the mere temperature of the body— for that 
effect is sometimes noticed when the heat itself is moderate — 
and it appears chiefly in those fevers which are of a contagious 
nature, as in jail fever, cynanche maligna, yellow fever, 
scarlatina, and dysentery. Pringle has noticed it particularly 
in the last mentioned disease. 

This typhoid stage of fever shows itself in the secretions and 
excretions. The tongue, on this occasion, as in the preceding 
stages of fever, shows the condition of the system in this re- 
spect. 

I should here first remark, that the tongue, upon being put 
out, manifests the same tremor and loss of power that is exhi- 
bited in the hand, or in other muscles of the body ; but the 
patient sometimes is incapable of putting it out, though he un- 
derstands you when you request him to show it ; and if he has 
strength to put it out, such is the state of his mind, that he 
perhaps keeps it out until you direct him to withdraw it. In 
this stage of fever, you now find the tongue of various colours ; 
sometimes of a dark crimson red, and perhaps effusing blood 
from its edges. In other instances black, and even coated 
with a dark, dry crust — in others, of a dark brown, with a 
black line along the middle of it ; and occasionally I have seen 
it exhibiting even a greenish hue. But we must except from 
this description the plague and yellow fever, in both of which 
diseases the tongue is frequently clean and moist throughout 
the whole progress of the disease. 



122 LECTURE IX. 

The tongue too, at the same time, will perhaps be found 
ulcerated, having aphthae, which also are of different colours, 
whitish, brown, ash coloured, and occasionally almost black. 
These aphthae or ulcers frequently extend to the gums, cheeks, 
and fauces ; and for the most part are fatal symptoms, especially 
in dysentery. The breath is also highly offensive. The urine 
is muddy like beer, depositing a heavy cloud of mucilage and 
earthy matter. The stools are acrid and frequent, and exceed- 
ingly foetid. The skin is hot and dry : — or, if moist, a slimy 
sweat appears to cover it, attended with petechiae, small spots 
resembling flea bites or the sting of mosquitos ; and these some- 
times, says Huxham, are of a dun colour : and according to 
Armstrong, in some instances they are black, resembling ink. 
Vibices, like the appearances left after the strokes of a whip, 
effusions of blood, and extensive discolorations, also appear 
at this period of fever. 

This vitiated state of body, showing itself in the state of the 
fluids as before intimated, may exist even without fever or the 
waste of the nervous excitement, as in scurvy, and the disease 
hence denominated petechiae sine febre, the effects of a bad 
diet. See Adair, and the Edinburgh Journal. 

In the Medical Repository, vol. ii. p. 147, you will see a 
case of scurvy produced by the excessive use of hickory nuts. 
According to Beddoes, scurvy is owing to the want of oxygen. 
Hickory nuts we know to consist chiefly of oil, that is, of hy- 
drogen and carbon. Upon these the child was fed for three or 
four weeks. The consequence was, as perfect a case of scurvy 
as is produced at sea by the exclusive use of animal food. It 
was cured by the use of fresh acescent vegetables. The author 
of that communication proceeds to remark most justly, that the 
humoral pathology is too much neglected. 

In typhus fevers, not only the fluids are affected, but this 
vitiation is conjoined with a general expenditure of the excite- 
ment of the solids. In this state too, as I have already re- 
marked, the vitiated fluids create a new fever in the system, a 
secondary fever. The excretion from the lungs is also changed 
in this stage. Instead of the natural sputa, the mucus becomes 
viscid and glassy, with great loss of power in the muscles to 
expectorate it ; especially if the lungs have been the seat of 
irritation, as in peripneumony. In some instances the dis- 



THE TYPHOID STATE OF FEVER. 123 

charges from the lungs are dark coloured. The disease pro- 
ceeding, the lungs become insensible to the effused fluids, until 
they may be collected in considerable quantities, when a vio- 
lent exertion is made to unload them of the matter oppressing 
them. The patient now becomes totally unconscious of exter- 
nal objects. This is not all : he is also insensible to those 
events which are ever going on in the system itself. He passes 
his stools and his urine involuntarily, taking no cognisance 
of them. The discharges themselves are changed in their 
quality, as well as poured out in an inordinate quantity. Diar- 
rhoea, at this stage of the disease, is a very common occur- 
rence, and generally proves fatal. A great flux of humours 
is sometimes at this period suddenly poured into the intestines, 
which as suddenly destroys the patient. I have recently seen 
a fatal case, in which destructive diarrhoea was induced by the 
use of porter, given in this irritable state of the intestines. 

The urine, too, is passed in considerable quantities, and some- 
times of a dark colour, resembling broken blood or coffee- 
grounds. In other cases the bladder becomes insensible, though 
full of water ; and is so much distended, that it is incapable of 
the contraction necessary to evacuate it — yet it proves a source 
of irritation to the patient, though he is unconscious of it. 
The catamenia also, at this period, in some cases become 
excessive, attended with a disposition to haemorrhage from 
almost every vessel of the body. Thus we see at this period, 
haemorrhages to take place from the nose, the gums, the ears, 
the lungs, tinging the expectoration, and even the saliva. Si- 
milar effusions of blood take place from the stomach and the 
liver, in the form of black vomit ; from the intestines, the kid- 
neys, and the bladder, resembling worms, — the blood taking 
the shape of the ureters or urethra through which it passes. 
In like manner, blood flows from the surface of blisters and 
of ulcers : veins too, that have been opened in the beginning 
of the disease, now bleed afresh ; wounds that had been long 
closed (for twenty or thirty years, says Huxham,) are opened 
anew. Even the sweat itself, is also occasionally stated, in 
some malignant cases, to be tinged or coloured by blood poured 
out from the relaxed vessels of the surface. This is certainly 
not surprising, after the ecchymoma or effusion under the skin, 
which we have noticed. Of the blood drawn in malignant 



124 LECTURE IX. 

fevers, we have already spoken very largely, viz. its fetor, its 
dissolved state, the rapidity with which it runs into putrefaction. 
The disease advancing, the sweats become profuse, clammy, 
and cold. The evaporation is so great, and the powers of life 
so quickly diminishing, that the whole body rapidly loses its 
temperature, especially the extremities, viz. the hands, feet, 
legs, nose, and the ears. The same loss of contractile power 
existing in the vessels upon the different surfaces of the body, 
(I mean both the internal and external surfaces,) and the power 
of the absorbents being at the same time impaired, the fluids 
are consequently effused, and accumulated in most of the cavi- 
ties of the body; as in the ventricles of the brain, producing 
stupor; in the chest, creating an additional source of laborious 
respiration ; in the pericardium, showing itself in an oppressed 
state of the heart, and an irregular action of that viscus. In 
the abdomen also, large collections of water have been some- 
times found. And in the last stage of fever, such effusion has 
occasionally produced hydrocele. I have seen such a case 
myself. 

The eyes now become insensible to their natural stimulus, 
the light — they remain half closed, the patient winking very 
rarely. The thinner fluids become evaporated, leaving a glassy 
and viscid matter covering the balls of the eyes. The eyes at 
the same time remaining open, the vulgar suppose, as they 
express it, that the " strings of the eyes are broken." And as 
far as it regards the power of the muscles of the eyes to close 
them, they are right, for that power is now destroyed. The 
sense of hearing too is lost — for the patient is roused with the 
greatest difficulty. The taste and sense of feeling are also de- 
stroyed or greatly impaired. The lungs partake of the same 
insensibility — the fluids effused in the bronchia? and upon the 
cells of the lungs, collect in considerable quantity. Hence, the 
air passing and repassing through this fluid thus accumulated, 
occasions a rattling noise ; respiration becomes irregular, with 
a total inability to expectorate. The power of the muscles is 
also destroyed. The patient is unable to swallow— the muscles 
of the pharynx and oesophagus partaking of this inability, and 
losing their contractile power, the smaller vessels cease to 
beat ; the circulation in the smaller distant vessels ceases to be 
performed, or is not to be perceived ; the sphincters of the 



THE TYPHOID STATE OF FEVER. 125 

anus and bladder are totally relaxed ; every exhalent vessel 
loses its contractile power. But this loss of tone is not con- 
fined to the muscular fibre, showing itself in the various systems 
of vessels ; but also in the organs of voluntary motion. The 
limbs sometimes become palsied ; a constant twitching or sub- 
sultus of the tendons and muscles takes place ; and occasionally 
general convulsions. And these, when they occur in the last 
stage of fever, are for the most part instantly fatal. But where 
the exhaustion does not show itself in this extreme, the debility 
is still manifest. The body slides down to the lower part of 
the bed, owing to the action of the flexor muscles, which retain 
their power of action a much longer time than the extensors. 
Hence old men have their bodies bent forward. The same 
thing is observed with debauchees, who, by their mode of life, 
induce a premature old age. You will read a very interesting 
chapter on this subject by Richerand, in his Physiology. He 
has given a very lucid account of the predominance of the 
flexors over the extensors, as displaying itself in great exhaus- 
tion of the system, and immediately before dissolution. Upon 
the same principle, in this advanced state of fever, when about 
to prove fatal, the limbs are bent, the thighs on the body, and 
the legs on the thighs, as in sleep, but the patient lying on his 
back. Hence this itself is an unfavourable symptom, (as well 
as the flexed state of the limbs, and the action of the flexors 
in dragging the patient from the upper to the lower part of the 
bed,) for it shows the incapacity of the muscles for the exer- 
tion necessary to sustain the body on the side, which is always 
done by the action of the muscles. I have known an excep- 
tion, however, in a gentleman of this city. The patient died 
lying on his side, owing probably to a paralysis of one side of 
his body. 

The position of the patient in sickness should be constantly 
attended to by the physician, as it leads to important infer- 
ences. Accordingly, Hippocrates observes that * the physician 
should find his patient lying upon his side, with his neck, his 
arms, and his legs a little bent, and his whole body in an easy 
posture; for persons in health generally lie in that manner;" 
and adds, that " if the patient cannot maintain his situation, and 
is apt to slide to the foot of the bed, it is a most alarming 
sign." Prognostics, sec i. Aph. 14, 16. Remember, then, that 
12 



126 LECTURE IX. 

the flexor muscles are the first to live and move, and the last 
to die, — as is seen exemplified in the foetus in utero, and the 
patient in death. 

The muscles of voluntary motion belonging to the face be- 
come relaxed. The natural expression of countenance being 
impaired in connexion with the emaciation that now takes 
place, produces that change which is denominated the fades 
Hippocratica^ from the admirable description given of it by 
Hippocrates in his Prognostics.* At this time, too, we often- 
times see in the patient a likeness to his relations, which in 
health was never observed — that is, it shows itself in the less 
changeable parts of the body, the bones, though not in the soft 
parts, which now have nearly disappeared in the emaciation 
that has been induced. 

The countenance, like the limbs, becomes of a livid pale 
colour, owing to the blood collecting about the heart, especially 
the right side of the heart — its force in throwing it to the ex- 
tremities being diminished. The cheeks become hollow ; the 
nose pinched ; the nostrils dilate at every inspiration; and death 
soon terminates even these imperfect efforts of the vital func- 
tions. After death, the body being examined, we find a variety 
of appearances which indicate the injury which particular 
parts may have sustained in the tumult and violence of the 
fever the patient has suffered. Sanious effusions are sometimes 
found in various cavities, as in the brain, in the chest, in the 
belly, and occasionally in the cellular membrane of the extre- 
mities. Where the patient does not die from typhus, dropsy 
accordingly is not an uncommon consequence or sequela of the 
disease. Sometimes too, purulent collections are met with in 
the brain, as noticed by Pringle. Similar collections also ap- 
pear in the liver and the lungs, particularly where a predispo- 
sition existed to those last mentioned diseases, especially to 
phthisis. Inflammation, or an engorged state of the vessels 
of the brain or stomach ; sphacelus of the latter organ and of 
the intestines, as in yellow fever and spotted fever, are some- 
times discovered after death. This last mentioned fever, I 

* See the Prognostics and Crises of Hippocrates, translated from the Greek, 
with critical and explanatary notes, by Dr. Ducachet, a graduate of this Univer- 
sity, p. 15, 



THE TYPHOID STATE OF FEVER. 127 

may just remark, is denominated in the Medical Repository 
the new fever ; whereas, it is the old-fashioned petechial fever 
of authors, and is well described both by the ancients and mo- 
derns. A part of its virulence has doubtless been created by 
the improper stimulant treatment pursued in it. To this source 
of excitement too, probably many of the appearances found 
after death in spotted fever may be ascribed. 

Such are the general symptoms of fever, and which we 
have seen to manifest itself, 

1st. By the irritation it excites in the brain and nervous sys- 
tem, affecting the mind as well as the body. 

2d. In the excitement it produces in the muscular fibre, 
showing itself not only in the muscles of voluntary motion, but 
also in the heart and arteries, in the exhalent and secreting 
vessels, not only expending the power of those vessels, but vi- 
tiating their functions, and thereby changing the quality of the 
materials they secrete. 

3d. In the absorbent system of vessels, embracing not only 
the lacteals, but the absorbents of the different surfaces and 
cavities of the body. 

4th. Its effects upon the fluids of the body ; and 

5th. The subsequent operation of the fluids thus vitiated 
upon the system, in exciting fever de novo, producing the ty- 
phoid form of fever, and this terminating in debility, putre« 
gcency and death. 



128 



LECTURE X 



THE CAUSES OF FEVER,— PREDISPOSING AND EXCITING CAUSES, 



Having taken a general view of the phenomena of fever, as 
it affects the various parts of the system, we are now led to 
inquire what are the causes from whence these phenomena pro- 
ceed ? It is to be observed that physicians, when treating of 
diseases, make use of the term cause with great latitude of 
meaning, and in a sense sometimes very different from its ordi- 
nary acceptation in the writings of philosophers. It is there- 
fore necessary for us to know the several medical applications 
of it, or at least those which are in most frequent use. 

The causes of fever are very properly divided into remote 
and proximate causes. By remote causes they understand such 
as are comparatively less nearly connected w r ith the disease, 
though they are the agents in the production of it ; whereas the 
proximate are essentially and immediately so. They are indeed 
so inseparably connected with the disease, that they constitute 
the very condition or manner of its existence. 

The proximate cause is that — " Qua? prsesens morbum facit, 
sublata tollit, mutata mutat" — which being present, the disease 
is present; which taken away, the disease is removed; and 
which being changed, the nature and character of the disease 
becomes changed. Hence this distinction has been made be- 
tween the remote and proximate causes. 

The remote causes are again subdivided into two kinds, de- 
nominated predisposing and exciting causes. What then are 
predisposing causes? They are such as prepare the body, or 
render it more fit to be acted upon, by those agents which 
more immediately excite the disease. In other words, they ren- 



CAUSES OF FEVER. 129 

der it more combustible, while the exciting cause, the torch, 
lights the fire. Let us illustrate this subject by a few examples. 
In the production of a cholera morbus, we see these various 
causes exemplified — a debilited, irritable state of the stomach 
and intestines, is the predisposing cause ; an indigestible meal, 
as an oyster supper, is the exciting cause. These, again, pro- 
duce irritation, which, by inviting a great determination of bilious 
and other fluids into the intestinal canal, constitute the proxi- 
mate cause. In irritable bowels, a glass of cider will induce 
cholera or diarrhoea. Or in the debility induced by fever, por- 
ter will sometimes induce a catharsis, as in the case mentioned 
to you yesterday. 

2d. In the production of a common pleurisy, a peculiar frame 
of the chest, or irritability of the part, the consequence of a 
former attack, is the predisposing cause. Cold, heat, intem- 
perance, or violent exercise, may be the exciting cause. Irrita- 
tion in the pleura, producing a determination of blood to that 
part, and inflammation of that membrane, is the proximate cause 
of all those symptoms that make up the disease. 

3d. The convulsions of children furnish another example. 
Their sensibility of frame, at that period of life, or a peculiar 
nervous temperament, constitutes the predisposition; while 
worms, teething, variolous matter, or other causes of fever, 
are the exciting causes : but the proximate consists in the irri- 
tation so produced in the bowels, in the gums, or in the blood- 
vessels, as small-pox or measles, for either of these will produce 
convulsions. 

4th. Intermitting fever. — Debility from a former attack, or 
from other diseases, is perhaps the predisposing cause — marsh 
effluvia, the exciting cause — irritation of the nervous, and hence 
of the arterial system, constituting the proximate. Or perhaps 
marsh effluvia may be the predisposing cause. While cold, or 
heat, as by riding in the sun, or an indigestible meal, may be 
the exciting cause — yet the irritation which either of these may 
excite, is the proximate : not debility, which is an effect instead 
of being the cause. 

The predisposing causes, for the most part, are internal — ■ 

inherent in the system, and appertaining to it, as the various 

temperaments of body. This predisposition, however, is not in 

all instances essentially necessary to the operation of the ex- 

12* 



130 LECTURE X. 

citing causes. The body may or may not be debilitated ; yet 
the exciting cause may operate, and disease nevertheless be 
produced. Nor is it indispensably necessary that the predispo- 
sition be inherent in the system, though generally this is the 
case, as in the example above mentioned, where marsh effluvia 
are the predisposing causes, — in these it is an external agent. 

The exciting causes, again, are for the most part external, 
but not always so. When seated in the intestinal canal, as 
worms, indigestion, biliary calculi ; a peculiar condition of the 
fluids, as lithiasis ; or an hereditary taint, as scrofula or 
syphilis, they are interna], yet they are exciting causes. The 
exciting causes, too, are by some called the occasional causes, 
because they may or may not be present : but this is a bad 
term, as it is not appropriate ; for the predisposing causes are 
also sometimes occasional causes. 

I might go on to illustrate this subject by numerous other 
examples, as gout, apoplexy, &c. in which this distinction be- 
tween the predisposing causes and those more immediately ex- 
citing the disease, is very obvious. It is highly important for 
us to ascertain the remote causes of disease, inasmuch as this 
knowledge enables us very often to prevent diseases, and some- 
times to cure them. For instance : to remove from marsh 
miasma on both accounts, both to cure the disease and to pre- 
vent its return. In what then does the proximate cause con- 
sist, and what is it ? It is that state of the system, or of the 
part, not only in which the disease resides, but which keeps up 
the disease — which present, causes the disease ; which being 
changed, changes the disease; and which, taken away, re- 
moves the disease. Our knowledge of the proximate cause, 
therefore, is derived from the structure and functions of the 
part or of the whole system, which is the seat of the disease, 
of the remote causes, and the effects they produce. From 
these, and from these only, are derived the great general prin- 
ciples upon which we proceed in the cure of diseases. And 
until we have a correct and definite knowledge of the proxi- 
mate, as well as of the remote causes, we shall never under- 
stand the cure of diseases upon principle : — until then, we shall 
indeed be mere empirics ; for the proximate cause is correctly 
defined by the late Dr. Gregory, and by Gaubius, and by Cel- 
sus before him, in the language I have already quoted. 



CAUSES OF FEVER. 131 

Let me give you a few examples. — Dropsy, in some cases, 
arises from increased exhalation, the result of fulness and inor- 
dinate excitement of the arterial system: while in other in- 
stances it proceeds from a debilitated state of the arteries, the 
veins and absorbents ; i. e. the return of blood to the heart is 
retarded, and connected with it there is a diminished power in 
the absorbent system. Thus, then, dropsy arises from two oppo- 
site causes, and is of two kinds, sthenic and asthenic. The first 
occurs, perhaps, in a sanguine temperament, which is therefore 
the predisposing cause ; — intemperance, or other cause, pro- 
ducing plethora, is the exciting cause. In that case, increased 
action of the exhalents becomes the proximate cause. Here, 
then, you perceive, very clearly, the distinction between the 
proximate cause and the disease itself: — and we remove the 
disease by the means of diminishing such plethora and such 
increased exhalation. 

Again, the same disease, dropsy, arises from other circum- 
stances. It perhaps occurs in a phlegmatic temperament, or in 
feeble old age, as the predisposing cause. The patient has had 
a fever of some duration, which has left a debilitated state of 
body, particularly a loss of tone in the nervous system, and of 
the absorbents, which debility of the blood-vessels and of the 
absorbents constitutes, in this case, the proximate cause of the 
disease. This debility, as I have said before, may even exist 
in the smaller distant vessels of the arterial system, as well as 
the nervous and absorbent system of vessels. In either case, 
this debility constitutes the proximate cause; to counteract 
which, will effect the cure. Stimulants and tonics, the reverse 
of the means employed in the former case, are now our only 
resource. A second example that may be adduced, is nephral- 
gia, or spasm of the kidneys. Plethora is frequently the predis- 
posing cause of such an attack ; — cold feet the exciting ; — irri- 
tation in the part, the proximate cause. Our knowledge of the 
part, of the state of the whole system, and our knowledge of 
the causes, direct our remedies. 

In hysteralgia, plethora is the predisposing, excessive venery 
the exciting, irritation of the nerves the proximate. Lithiasis, 
or calculus, is another example. Here the predisposing, ex- 
citing, and proximate, are all united. The patient comes into 
the world with a redundant quantity of the lithic acid. It ac- 



132 LECTURE X. 

cumulates in his kidneys and bladder from his mode of living, 
the free use of wine, &c. ; and thus becomes the proximate, 
as well as the remote cause. 

So in gout — a sanguine temperament and free living predis- 
pose the body to this disease. Cold is the exciting cause. A 
determination to the extremity affected, producing inflammation 
in the great toe, becomes the proximate cause of the disease. 

In all of these diseases, our knowledge of the causes alone 
directs our prescriptions. 

The structure of the part, or of the whole system, the seat 
of the disease, therefore, must be known, as well as the cause 
or causes from whence it proceeds, to know the remedies which 
will be indicated. A few remarks upon each of these classes 
of the causes of fever will be necessary in this place. 

Predisposition, we observe, is sometimes hereditary, and 
sometimes acquired. It is hereditary in the different tempera- 
ments, as the sanguineous, the melancholic, the nervous, and the 
phlegmatic. The sanguineous predisposes to fever and the 
phlegmasia? ; — the melancholic, to dyspepsia, hypochondriasis, 
&c. ; — the nervous, to convulsions, hysteria, and other diseases 
of the class neuroses : while the phlegmatic temperament is 
peculiarly predisposed to dropsy> and other diseases of direct 
debility, as already noticed. 

The first of these temperaments, the sanguineous, is more 
especially predisposed to fevers and febrile diseases ; accord- 
ingly, this temperament stands at the head of the list of the pre- 
disposing causes of fever, and of the phlegmasia?. 

Plethora, in like manner, is frequently the predisposing cause 
of fever, as in the northern man, in the hot latitudes of the 
tropics. The fulness of his vessels gives the predisposition to 
be powerfully operated upon by heat ; and then, violent exer- 
cise and intemperance readily become exciting causes. But in 
some instances, plethora itself becomes the exciting cause, and 
produces apoplexy or inflammation of the brain. More fre- 
quently, however, in these cases, plethora merely predisposes ; 
and cold, or a full meal, particularly a hearty supper, proves 
the exciting cause. Extraordinary exertion, as stooping, cough- 
ing, &c, not unfrequently becomes the exciting cause. This 
exertion, particularly in coughing, interrupts the return of the 
blood from the head. The effects of vomiting have the same 



CAUSES OF FEVER. 133 

operation. Hence the obvious impropriety of emetics in such 
habit of body. I have known apoplexy thus induced more 
than once. 

Predisposition is acquired, as well as constitutional. 

1. It is sometimes the result of previous disease, as in cy- 
nanche tonsillaris, croup, &c. I have already told you of 
pleurisy occurring no less than twenty-one times in one individ- 
ual. The same remark will apply to fevers. Persons who have 
had intermitting fever, are peculiarly liable to its return from the 
slightest causes, without being exposed to the original cause 
which produced it. Galen tells of its having been renewed by 
the imprudent use of vegetable acids. I have known it repeat- 
edly renewed by excessive venery in a young gentleman of this 
city. Hence, it was observed, during the plague of Marseilles, 
that newly married people very generally suffered from the pes- 
tilence. Those who suffer an intermittent in the fall, are very 
liable to an attack in the spring. 

2. This acquired predisposition is often the effect of intem- 
perance in eating or drinking. 

3. The various passions, such as grief, anger, love, fear — all 
predispose to febrile attacks. Fear, especially, prepares the 
body to receive contagious diseases. It is noticed by Thucy- 
dides, that those who suffered much from fear or anxiety, were 
first affected in the plague of Athens, and were the most likely 
to be cut off by it. Diemerbroeck makes a similar remark : 
" Confidentes utplurimum serventur; contra, meticulosi facile 
corripiantur." — De peste, lib. i. c. viii. s. 9. 

4. Debility, the effect of a vegetable, spare diet, predisposes 
to intermitting and remitting fevers. This I had an opportu- 
nity of observing at my botanic garden at Elgin, on this island. 
The labourers employed there, suffered greatly from this cause; 
but my own family, who ate animal food, as usual, escaped. 

5. Debility, the effect of water-drinking, especially in those 
accustomed to the use of spirits or wine, is another predisposing 
cause. I heard the late Dr. Gregory say, that Dr. Kuhn, of Phi- 
ladelphia, when in Holland, was severely attacked with intermit- 
ting fever. He used nothing but water as a drink : whereas his 
comrades, thirteen or fourteen in number, who drank wine — his 
own father, the elder Gregory, among the rest, all escaped. I 
found, too, that the water-drinkers among my workmen at El- 



134 LECTURE X. 

gin, suffered from the prevailing fever, while the grog-drinkers 
went free. 

6. But the excessive use of spirituous liquors no less predis- 
poses to febrile complaints, and often, by the prostration they 
induce, to the typhoid form of fever. Hence yellow fever is 
generally fatal to drunkards ; or if they survive, as in the cases 
related before, it must be by the continuance of potent draughts 
of their accustomed stimulus. 

7. A vitiated state of the fluids predisposes to fevers, and 
fevers of the most malignant character. This state is frequently 
induced by salt meats, the want of fresh vegetables, and the 
excessive use of animal food. They produce a putrid colluvies 
in the bowels, and thence in the blood-vessels. Scurvy, dys- 
entery, and typhus fevers, are thus produced, as you will find 
by referring to Lind, Pringle, and Blane : and disease, once 
lighted up, soon destroys patients of this habit of body. 

8. A moist atmosphere predisposes to fever. Catarrh, pneu- 
monia, and phthisis, are hence the common diseases of our sea- 
board, and of Great Britain. The Irish employed to drain the 
drowned lands of Orange county, suffered exceedingly from 
this source of disease ; and very many fell victims to typhus 
fever. Standing immersed in water, by the day and week, must 
necessarily have exposed them to disease ; and that, too, of a 
malignant type. 

9. Climate predisposes to fevers. A hot climate, especially 
after a residence in a cold one, renders the stranger peculiarly 
liable to fever upon the slightest debauch or irregularity. A 
hot climate, too, of itself, begets great excitement, and is fol- 
lowed by debility, and consequently an irritability, which is 
easily acted upon by causes that, under other circumstances, 
would prove harmless. In like manner, the inhabitant of the 
torrid zone, coming to our colder latitudes, suffers febrile dis- 
eases, and especially the phlegmasia?, after the slightest ex- 
posure to exciting causes, which are innocent when applied to 
those habituated to our colder temperature. This fact should 
teach the youth who come from our southern states, to guard 
their persons by wearing flannel next the skin, and an addi- 
tional garment, to meet the frequent changes of weather they 
have to encounter in this climate. 

10. A vitiated atmosphere is another very frequent and fatal 



CAUSES OF FEVER. 135 

source of febrile diseases, by the predisposition it creates ; while, 
in other instances, it is an exciting cause of fever. Thus, if 
vitiated air, from putrid bilge-water on board ships — the air of 
jails and of hospitals — the confined dwellings of the poor — sail- 
ors' lodging-houses — of small, confined streets — the air of mar- 
ket-places — of docks — of privies, loaded with fermentable ma- 
terials, the product of decomposed animal and vegetable sub- 
stances, predisposes to fevers. And these, when thus produced, 
rapidly propagate themselves, as far as such atmosphere 
extends. In some instances, this vitiated air is said to be an 
exciting cause of disease, as in the manufacturing towns of 
Great Britain, and on ship-board, producing typhus fever. This 
we have seen frequently exemplified in Irish vessels. On board 
the Mohawk, with a hundred passengers, the disease broke out 
in the cabin and steerage. Though both occurred in the heat 
of summer, the fever was typhus fever, not yellow fever, which 
requires a greater degree of heat, and of longer continuance. 
It indeed requires the heat of the torrid zone, and that, too, 
must operate upon the northern man to beget that peculiar form 
of fever. Hence new-comers, not the natives of the tropics, are 
the subjects of it, both in the West Indies and South America. 
In our climate, such impure or vitiated air, doubtless may give 
birth to febrile diseases of the intermittent, remittent, and 
typhoid type. But the more malignant, and the more fatal 
form of tropical fever, I have never seen thus produced — 
though it is the belief of the majority of the physicians of this 
city, and of Dr. Rush and his disciples, in Philadelphia, that it 
is thus engendered in our own climate ! But whether begotten 
here, or introduced, such atmosphere as we have mentioned, 
during the warmer seasons of the year, readily multiplies and 
extends the poison engendered or introduced. But does it so 
multiply? and how does it multiply itself? 

We have already spoken of the assimilating fermentation, as 
it takes place in the human body, as in small-pox, and other 
diseases communicated by inoculation ; — we have also called 
your attention to the fact commonly observed, of the rapid dif- 
fusion of the putrefactive process among animal substances, 
when a taint of impurity, or foul materials may have been in- 



136 LECTURE X. 

troduced among them — as we have noticed in the process of 
packing beef or fish ; and as illustrated by the experiments 
made by Sir John Pringle upon eggs. An analogous multiply- 
ing power appears in the atmosphere when once infected by the 
introduction of a contagious disease; as dysentery, yellow 
fever, and others. It is accordingly remarked, that the disease 
so introduced remains limited, for a certain space of time, to 
the spot where it first made its appearance. Accordingly, I 
have observed, (for I have been an eye-witness of the facts I 
give you on this subject,) that in 1791, 1795, 1796, 1797, 1798, 
1805, 1819, and 1822, — the yellow fever appeared, not in the 
same part of the town, but at different parts, in every season 
of such visitation. It began in 1791, at Burling-slip. It did 
not appear at those constant deposits of filth, the Collect, 
(now "the Five Points") — the Fly-market — the Bear-market — 
Catherine-market, and other places proverbially filthy : but at 
entirely different spots of the city. In 1795, at Peck-slip ;■ — an- 
other year, at the Coffeehouse-slip ; — a fourth year, at the ship- 
yards; and twice at the Old-slip. At each of those places, 
the disease remained stationary for many days, (assuming 
the character of what would be denominated sporadic,) in- 
fluenced, in some respects, by the state of the weather, and 
the degrees of heat, moisture, and the state of the wind; but 
usually observing a definite period — insomuch that its subse- 
quent diffusion was at length uniformly anticipated by our citi- 
zens, as it had been in 1795, by that sagacious observer, the 
elder Dr. Bard. 

This is not all — it will perhaps appear to be totally suspended 
and gone, when, at the end of a certain period of time, (this, 
too, pretty uniformly, as it regards the period,) it again is sud- 
denly lighted up, and spreads extensively along in the vicinity, 
as an endemic ; but it is conveyed to other parts of the town, 
and forms new centres, from which it becomes extensively dif- 
fused. The epidemic, comparatively speaking, during the 
first few days perhaps, is confined to a single case, as in 
the case of Mr. Jenkins, in 1795; or in another year, 1791, 
when Gen. Malcolm was attacked. These cases die off. We 
hear no more of it. Some days (say from ten to fourteen) in- 
tervene — it re-appears in the same neighbourhood — many now 



CAUSES OF FEVER. 137 

sicken, and a general fatality follows, creating alarm and con- 
sternation throughout the city.* 

In the history of the Plague of Marseilles, the same deceit- 
ful pause is frequently recorded by the historians ; after which 
new centres were formed, which scattered the pestilential rays 
to such an extent as to involve a whole city in distress and 
death. I must caution you against Dr. Miller's incorrect state- 
ment and false reasoning, the result of an error in his premises. 
I refer to his report as resident physician, in which he over- 
looks the first point where the poisonous material showed 
itself; — but most carefully enumerates all the second, sub- 
sequent parts of the city to which it was introduced from 
the first. On the contrary, the Board of Health, of which he 
was a member, In several years — in 1795, 1798, and others, 
(see Hardie's Reports, taken from the Minutes of the Board of 
Health,) stated distinctly and emphatically to the citizens, that 
the disease was so exclusively located ; and advised an aban- 
donment of such parts of the town. Many of the cartmen, 
carpenters, and masons, who worked at the new buildings at 
the Coffee-house slip, and returned to their respective homes, 
principally on the north side of the city, and Rutgers' grounds, 
sickened. The Board traced all their first cases to that source, 
and advised the abandonment of that part of the city. This 
was communicated to me by Dr. Douglass, a member of the 
Board at the time. But no — the citizens remained, tied as by a 
spell to the fatal spot. — It spread. — Its new lines of demarcation 
were again pointed out by the corporation, with threats to com- 
pel an abandonment, but without effect. Our citizens resorted 
to it still, conveyed the poison to other parts of the city, and 
thus involved a considerable portion of the city in one scene of 
mortality and distress. This assimilating process became al- 
most manifest to the senses, in this gradual extension of the 
disease/)- 

See my letter to Dr. Chisholm, and his criticisms on Dr. 
Miller's Report. See also Hardie's various reports, prepared 
under the direction of the corporation ; and in these you will 

* Rev. Dr. Smith, of Princeton College, N. Jersey, most wisely wrote me a let- 
ter, in 1805, cautioning me against the evils of neglecting those measures which 
are necessary to guard against the subsequent multiplication of the disease. 

t See my Discourse — Appendix to Thomas's Practice of Physic. 
13 



138 LECTURE X. 

find an ample refutation of the errors, both in the premises as- 
sumed by Dr. Miller, and in the conclusions he has deduced 
from them. 

11. Contagion itself, like marsh miasma, in some instances 
becomes a predisposing, as well as the exciting cause of fever. 
The person under its influence is even conscious of a slight de- 
gree of febrile irritation in his system, but which is frequently 
counteracted by temperance and attention to his evacuations ; 
but is, however, readily called into action by an exciting cause, 
as fatigue, cold, heat, irregularity in diet, intemperance, loss of 
sleep, &c. 

During our epidemics, I experienced frequently the sensation 
of burning hands, a dry skin, and vertigo ; my whole sensations 
were disturbed. But by care in my mode of living, the liberal 
use of fruits and vegetables, with the occasional use of laxative 
medicines, I was enabled to resist the disease a long time. The 
same observations were made by Dr. Rush. (See his account 
of his own feelings and situation.) 

Nor, as I have said before, are marsh effluvia always an ex- 
citing cause of intermittent fevers. Like contagion, they also 
are sometimes the predisposing cause. For the most part, how- 
ever, the reverse is the case — that the fatigues of the camp, a 
hot climate, excessive exercise, and intemperance, by debilitat- 
ing, and thereby deranging the functions of the system, predis- 
pose the body to the action both of contagion and of marsh 
effluvia as the exciting cause. 



139 



LECTURE XL 



EXCITING CAUSES OF FEVER— EXERCISE, HEAT, COLD. 



We now proceed to take a view of the second class of the 
remote causes, viz., those which more immediately excite fever, 
or febrile diseases ; — they are hence called exciting causes. 
The first of these, is violent exercise. By the excitement it 
produces upon the nervous system, its effects are also extended 
to the moving fibres of the heart and arteries, and the other 
parts of the system. Stage riding, violent and long-continued 
exercise on horseback, are hence frequently the exciting causes 
of fever ; more especially when conjoined with the usual ac- 
companiments, spirituous liquors, and other stimulant drinks, 
which the traveller generally has recourse to, in some shape or 
other, instead of plain water or lemonade, which should be 
his only beverage during the excitement created by this inor- 
dinate exercise. On the contrary, the gin sling, the pot of gin- 
gered cider, the mint cordial, the glass of bitters, or some other 
form of alcohol, are the usual juleps of the traveller, in most 
countries, and rarely fail to excite a febrile state of body. 
Some years since, travelling to Albany, in company with a 
gentleman of high distinction, I drank water — he took his mug 
of cider, well powdered with ginger, at most of the houses at 
which we stopped. When we arrived at the end of our jour- 
ney, he was so much excited that he required two or three 
days to calm the commotion produced, while I felt compara- 
tively little or no effect from the journey, although it was in 
the winter season, and the roads were unusually rough. I am 
frequently called upon to prescribe for fever, thus induced by 
violent exercise, and this species of intemperance, combined. 



140 LECTURE XI. 

Inordinate exercise of the mind, especially when not relieved 
by regular sleep, is also an exciting cause of fever. I am 
now attending a gentleman, who has been ardently engaged 
in preparing a work for the press, and who, in consequence 
of want of his accustomed sleep, in connexion with intense 
application, has been attacked with continued fever, and in 
whom the head is particularly affected. 

2. Heat is another and a frequent cause of fever. By heat, I 
mean caloric, the matter, not merely the sensation, of heat — for 
heat, like cold, is absolute or relative. The absolute heat of a 
body denotes the quantity of caloric such body contains, as 
measured by the thermometer or pyrometer, while the relative 
heat only signifies its comparative temperature; i. e. compared 
with itself, or with other bodies, and refers itself more espe- 
cially to our feelings as our measure. We shall illustrate this 
directly, when speaking of cold ; and confine ourselves at pre- 
sent to the effects of caloric upon the body; more especially 
as communicated by the direct rays of the sun, or generated 
in the system by other causes. In either case, it occasionally 
becomes the exciting cause of febrile action. We perceive the 
effects produced upon our system by the direct rays of the sun, 
in the expansion which it gives to our fluids in the spring of the 
year, especially when its influence is suddenly communicated, 
as after a severe and cold winter. We then become sensible 
of its effects in all our feelings, producing headache, vertigo, 
numbness, and tingling in the extremities ; and if not counter- 
acted, these are frequently followed by inflammatory fever 
(synocha,) or by haemorrhages, in the form of haemoptysis, 
epistaxis, or apoplexy, (the hemorrhagia cerebri, as Hoffman 
calls it,) or perhaps palsy is produced by the same cause. In 
some instances, serous effusions in the cavities of the body are 
the result. Or we see its effects in the production of gout, or 
of some of the phlegmasia?, which are all readily induced in 
that season of the year. But the direct effects of heat are not 
only perceived in our feelings, or in its operation upon the ex- 
citement of the system. It shows its effects upon our secre- 
tions. The skin, the kidneys, and even the seminal vessels, 
show its operation in this respect. For in the spring of the 
year, the expansion of the fluids is no less manifest in the ani- 
mal body, than it displays itself in the rising of the sap in the 



EXCITING CAUSES OF FEVER. 141 

vegetable structure. In like manner, upon a change of climate, 
from a cold to a hot one, we are liable to a coup de sole'd, a 
stroke of the sun as it is called ; that is, to phrenitis, and to 
apoplexy. A great number of such cases occurred here in the 
summer of 1811. In cold weather, also, apoplexy is a disease 
of frequent occurrence. The same effect is produced by ap- 
parently opposite causes. But, in truth, it is resolvable into 
the same as it regards pressure on the brain. 

The causus or ardent fever in hot latitudes in general, — the 
yellow fever in the West Indies and South America, the stran- 
gers' fever in the southern states, and indeed in New York, 
(foreigners especially, who are unaccustomed to our heat and 
our climate, suffer from this latter form of fever,) are all at- 
tributable, in a great degree, to the effects of heat. The effect 
of heat in aggravating the remitting fever of the southern states, 
which exhibits a much more inflammatory type than the same 
disease in the more temperate latitudes, you will see admirably 
described by Dr. Norcom, in his account of the fevers of 
North Carolina. This form of fever, in consequence of the 
inflammatory action which is superinduced as the effect of heat 
and habit of body, is very generally confounded with the yel- 
low fever of the West Indies! It doubtless, excepting the 
plague, is the nearest approach to yellow fever that exists : — 
but although they are thus nearly allied, they are asymptotes, 
which can never meet. There are some lines of discrimination 
between them, that are as fixed as those which .separate the 
small-pox from the measles, or the plague of the Levant from 
the ordinary bilious remittent of the United States. 

The heat of climate or season, .especially when blended with 
exercise, readily produces fever, as in the case of Dr. Rowe, 
a pupil of mine, who went to settle himself at St. Croix. But 
cases of fever produced by the heat of climate, and espe- 
cially when in co-operation with severe exercise, hard labour, 
and perhaps intemperance, are met with in every book of 
practice : I need only refer you to those of Blane, Pringle, and 
the Linds. Our own annual observation also furnishes constant 
testimony of the effects of heat, as an exciting cause of fever 
and of febrile diseases. 

3. Cold is among the most frequent of the exciting causes 
13* 



142 LECTURE XI. 

of fever. It is with cold as with heat ; the term has two 
meanings. It denotes the sensation of cold- — it also signifies 
the real diminution of temperature, or the abstraction of 
caloric. These are two totally different things, and are not 
always connected. We feel hot, or we feel cold, when we are 
not really so, as we have already observed when describing 
the symptoms attending the first stage of fever. Our feelings 
not only depend upon the condition of the nervous system, but 
in this particular they also depend upon our previous sensa- 
tions, and upon our previous real degree of heat or cold, ac- 
cording as our temperature may be above or below the healthy 
standard. For example, immerse the hand in water at 100° — 
97 A , which is the natural temperature, will in this case be cold 
to our sensations. Again : immerse the hand in a mixture as 
low as 50°. In that case, 60° or 70°, though below the natu- 
ral temperature, will still be hot to our feelings as the test. 
Our sensations, therefore, depend upon our preceding feelings 
and our preceding temperature. Heat and cold are conse- 
quently very properly called relative heat and relative cold. 
This distinction is of great importance, as applied to the va- 
rious states of the human body. For instance, it is of great 
importance in the treatment of asphyxia from cold ; because, 
with this distinction before us> we adjust or proportion the 
temperature of our applications to that of the body to be acted 
upon. We are hence taught to apply our heat gradually, be- 
ginning a few degrees only above the temperature of the 
frozen body. In such case we begin with snow, which is 
comparatively warm. We next apply cold water, that is, 
water at its ordinary temperature, which is still warm enough 
to be a stimulus to the still colder body. We thence proceed 
to the use of water moderately warm, &c. Upon the same 
principle the application of spirits of wine, spirits of turpen- 
tine, and other spirituous and highly stimulating applications 
to burns are recommended, inasmuch as they constitute the 
next grade of stimulus to the part. Hence, the absurdity of 
cold applications, especially when conjoined with the sedative 
effects of lead, in the form of saturnine solutions, frequently 
prescribed by physicians who do not advert to this principle. 
Without observing these grades of temperature in our several 
applications, we may waste the small portion of excitement 



EXCITING CAUSES OF FEVER. 143 

which remains in the body whose animation is suspended. As 
in the management of the spark of culinary fire, we extinguish 
it by a strong blast, so by an excessive stimulus, dispropor- 
tionate to the excitement, we totally extinguish the small and 
feeble remains of the vital principle. This is no less applica- 
ble to the part than to the whole system. Absolute cold, as 
applied to the living body, is the real diminution of its tempe- 
rature below the healthy standard of 97^°. And except when 
the surrounding bodies are below 62°, it is remarkable that we 
retain that temperature, that is, the body being in a healthy state. 
But in debilitated habits, where, from want of nourishment, or 
debility otherwise induced, the heat-generating power of the 
system is certainly diminished in proportion to the weakened 
powers of the vital principle — in that case, the heat is dimin- 
ished and not supplied accordingly, and the patient suffers; as 
was the case with the people working at the Walkill, in drain- 
ing the drowned lands. Although the temperature was not as 
low as 62°, they could not counteract the abstraction of their 
caloric at that higher temperature. Fevers, then, are produced 
from moisture alone, and which, judging from the season of 
the year, could not have been as low as 62°. 

It is well ascertained, that air at 62° will not reduce our 
temperature, though denser bodies will, in proportion to their 
density. For in that proportion, as well as according to their 
own temperature, they abstract our heat : as mercury and 
water, which possess a conducting power in proportion to their 
density, and abstract it more readily than the atmosphere. 
Although, therefore, our bodies could resist an air at 62°, we 
could not resist the loss of our heat at that degree, immersed 
in water or mercury. On the contrary, we should soon be 
frozen. 

In like manner, in air beloio 62° our heat would be abstract- 
ed. Fordyce, Hunter, Crawford, and Sir Charles Blagden* 
by their celebrated experiments, (see Phil. Trans, vol. lxv.*) 
have also shown the wonderful power which the human body 
possesses of resisting heat, by preserving its temperature within 
a very few degrees of the natural temperature, although the 



* See also Hunter on the Animal Economy, and Crawford on Animal Heat, 
See also Gamett's Lectures on Zoonomia. 



144 LECTURE XI. 

surrounding air was heated to a degree far exceeding - 97 J°, viz. 
at the high degree of 230° — a heat sufficient to roast eggs and 
to broil beefsteaks. Yet that heat was counteracted by the 
constant evaporation going on from the surface of their bodies ; 
the fluid issuing from their bodies combining with the caloric 
of the body from which it proceeded, leaving it relatively 
cool. How important then is the inference in favour of per- 
spiration counteracting a febrile state of the body by the ab- 
straction of heat. Hence, as before observed, fanning their 
bodies scorched them, by bringing a new stratum of heated air 
in contact with their surfaces, that had been thus relatively 
cooled. In like manner, the body has the power of resisting 
cold for a certain length of time, as well as heat. 

Delile has observed a degree of cold in Siberia, 70° below 
the zero of Fahrenheit, notwithstanding which, animals lived. 
Professor Gmelin has seen the inhabitants of Janiseisk, under 
the fifty-eighth degree of northern latitude, sustaining a degree 
of cold which, in January, became so severe that the spirit in 
the thermometer was 126° below the freezing point. Professor 
Pellas, in Siberia, those who visited Hudson's Bay, and the late 
navigators in search of a north-west passage, have experienced 
a degree of cold very nearly equal- to this. Hence, then, we see 
the wonderful power of the system in generating a greater degree 
of heat, when surrounded by so cold a medium. But in a cold 
climate and atmosphere, does the body generate more heat 1 
Yes it does, and this must necessarily be the case, or death must 
ensue. Another question then arises, in what manner is this 
effected 1 To answer this question, it is necessary to remem- 
ber, that the heat of the body is chiefly generated by the de- 
composition of oxygen gas in the lungs during the process of 
respiration. The atmosphere, we must recollect, consists of 
two species of air — the one oxygen gas, or vital air, the other 
nitrogen gas — the one capable of combustion and of support- 
ing life — the other not ; and that these two gases exist in the 
proportion of nearly one of the former, to three of the latter. 
We also know, that air which has undergone the process of 
respiration, is found to contain a mixture of nitrogen and car- 
bonic acid gas, with a small quantity of oxygen gas, and a 
considerable quantity of water thrown off in the form of 
vapour. But from a variety of facts, it is ascertained that 



EXCITIXG CAUSES OF FEVER. 145 

oxygen gas is decomposed in the lungs during respiration ; 
that a small and inconsiderable part of it unites with the iron 
in the blood, converting it into an oxide — that, 2dly, another 
and greater portion of it unites with the carbon brought by the 
venous blood from all parts of the body to the lungs, and thus 
forms carbonic acid gas. And that, 3dly, in addition to the 
watery fluid exhaled, another portion unites with the hydrogen 
brought in the same manner by the blood, and forms the hali- 
tus or vapour. Thus, then, we account for the appear- 
ance of those several products of respiration. Hence, we 
see that the explanation of the manner in w T hich animal heat 
is evolved, follows as a simple and beautiful corollary from 
the theory of combustion. That respiration is an operation in 
which oxygen gas is continually passing from the gaseous to 
the concrete state, and that the heat which it held in its 
gaseous form is given out at every inspiration ; and that this 
heat being conveyed by the circulation of the blood to all parts 
of the body, is a constant source of heat to the system. These 
facts lead to the solution of another interesting phenomenon. 
They enable us to explain the reason why the animal body 
preserves the same temperature in all the various changes 
which occur in the temperature of the atmosphere, whether in 
summer or winter, on the frozen plains of Siberia, or the burning 
sands of Africa; for it is a fact, that man breathes the atmo- 
sphere of this earth, whatever may be its elevation, its tempera- 
ture, its dryness or moisture, w r ith nearly the same results. The 
aeronaut who soars miles above the earth, or the miner below 
its surface, the peasant of the Alps, or the half frozen Lap- 
lander, the sirocco-breathing African, the inhabitant of the 
sandy deserts, or the Hollander in the midst of his dykes and 
canals, are by habit rendered equally exempt from the perni- 
cious effects of those opposite states of the atmosphere. In 
winter, we know the air is condensed by the cold, and conse- 
quently contains more oxygen in proportion to its quantity or 
its bulk. The lungs, therefore, receive at each inspiration a 
greater quantity of oxygen in the same bulk of air. The heat 
extricated will be consequently proportionally increased. In 
summer, on the contrary, the air being rarified by the heat, 
the same quantity of air will contain less oxygen in proportion 



146 



LECTURE XI. 



to its bulk ; consequently, a less quantity of oxygen gas will 
be received by the lungs in each inspiration ; and the heat 
which is extricated, will necessarily be less. For the same 
reason, in northern latitudes the heat extricated by respiration 
will be much greater in proportion to the bulk of air respired 
than in the southern. By this simple and beautiful contrivance, 
nature has modified the extremes of climate, and enabled the 
body to bear vicissitudes which would otherwise destroy it. 
Thus then, the body, as said before, possesses the power of re- 
sisting cold for a certain length of time ; but continued in con- 
tact with a body at 62°, especially a dense body, as water, the 
system loses its caloric faster than it can be restored, — a torpor 
of the system ensues, — gangrene follows, and at length life is 
exhausted. But though the human body has been so wisely 
constructed as to bear, without inconvenience, a considerable 
and even sudden variation of temperature; yet, I repeat it, 
there is a limit, below which the diminution of heat takes place 
faster than it can be regenerated ; and if this situation be con- 
tinued, the heat of the animal must be diminished — the func- 
tions lose their energy* — the sensibility of the body is destroyed 
— an insuperable inclination to sleep succeeds, which, if the 
unfortunate sufferer indulge, his sleep is death. This is con- 
firmed by the very interesting account given in Cook's Voyages, 
of the sufferings of Dr. Solander, Sir Joseph Banks, and other 

* I may mention here, although not immediately connected with our subject, 
the agency of cold in producing scurvy. Captain Morrik, a Dane, wintered in 
the year 1619 in Hudson's Bay, lat. 63° 20'. He was well supplied with pro- 
visions, and had with him sixty-four persons. All perished of scurvy, except 
himself and two of his men. In 1633, two experiments were made by the Dutch ; 
one at Spitzbergen, the other on the coast of Greenland, in lat. 77° or 78°. Seven 
sailors were left at each place ; and all died of scurvy at both. Captain James, 
an Englishman, with a crew of twenty-two persons, wintered on an island in 
Hudson's Bay. They were compelled to labour out of doors during the severest 
weather ; but only two died. Another singular fact is related. In one case, 
eight Englishmen, and in another, four Russians, were left by accident in the 
Arctic region, without provisions. In the ensuing spring, the Englishmen all 
returned home. The Russians all survived six years — then one of them died. 
The others were shortly after rescued. It is to be remarked, that those who 
died, in all the instances mentioned, fed on salted provisions, led an indolent life, 
and used spirituous liquors : those who survived, used fresh animal food, drank 
water, and used much exercise. 



EXCITING CAUSES OF FEVER. 147 

fellow-voyagers, some of whom perished on the heights of 
Terra del Fuego. 

Dr. Solander, who had more than once crossed the mountains 
which divide Sweden from Norway, well knew that extreme 
cold produces this irresistible torpor, and propensity to sleep ; 
he therefore conjured the company to keep themselves always 
in motion, whatever exertion it might require. " Whoever sits 
down," said he, " will sleep ; and whoever sleeps, w r ill wake 
no more." Thus admonished and alarmed, they proceeded ; 
but while they were upon the naked rocks, the cold was so in- 
tense as to produce the effects which had been apprehended. 
Dr. Solander, himself, was the first who felt the inclination 
against which he had warned his companions, and insisted 
upon being allowed to lie down. Mr. Banks, (the late Sir Jo- 
seph Banks,) entreated and remonstrated in vain. Solander laid 
down upon the ground, though it was covered with snow — it 
was with the greatest difficulty he was prevented from sleep- 
ing. One of his black servants also began to linger, having 
suffered from the cold in the same manner as the Doctor. 
Partly by persuasion, partly by force, they were carried for- 
wards ; but they soon declared they would go no further. Sir 
Joseph again entreated and exhorted, but without effect. When 
the poor black was told that if he did not go on he w^ould 
shortly be frozen to death, he answered, that he desired nothing 
so much as to lie down and die. Dr. Solander said that he 
would go on if they would first allow him to take some sleep, 
though he had before told them, that to sleep was to perish. 
They both, in a few moments, fell into a profound sleep ; and after 
five minutes, Sir Joseph happily succeeded in awaking Dr. So- 
lander, who had almost lost the use of his limbs. The muscles 
were so much shrunk that his shoes fell from his feet; but 
every attempt to recall the unfortunate black to life proved un- 
successful. See Garnet's Zoonom. p. 32. 

So far, then, cold, when continually applied to the body, 
exerts a directly sedative effect upon the system, by its lower 
temperature, and its long continuance ; but cold, when it is 
suddenly applied, and for a short space of time, manifests a 
contrary operation — that of a stimulant to the part, or to the 
whole system — depending, for its effects, upon the previous 
temperature, and previous feelings of the body ; for the condi- 



148 LECTURE XI. 

tion of the nervous system, the power of the vital principle, 
controls and influences the effect of this, as well as other appli- 
cations made to our bodies ; for we are not to reason of ani- 
mate as of inanimate bodies. Cold, then, is stimulant or seda- 
tive, depending on our previous temperature, and our previous 
sensations, as well as the time, manner, and other circumstances 
of its application. We are powerfully excited by a change of 
season : — after the relaxing effects of a hot summer, we are all 
animated by the cold of autumn or of winter ; — this is not only 
observable in man, but the horse, and almost every other ani- 
mal are in some manner excited by the first impressions of the 
cold of winter. 

Diseases, too, acknowledged by all to be diseases of excite- 
ment, as the phlegmasia?, are produced in great abundance by 
this cause. The dews and cold of the night, after a hot day, 
in like manner produce diseases. The system being previously 
excited, and the perspiration, which had been flowing freely, 
becoming suddenly arrested, dysentery is produced ; which is 
another disease of acknowledged excitement. It is well named 
by Dr. Sydenham febris introversa — a fever turned in upon the 
bowels. Cold, in the manner mentioned, is one of its most usual 
exciting causes. 

Yellow fever, another disease of excitement, is also frequently 
thus produced in the torrid zone, by exposure to the relatively 
cold air of the night, especially where predisposition exists ; 
and perhaps the materies morbi may already have been received 
into the system. Malignant fevers, where a predisposition 
exists, are frequently thus excited by the cold air and dews of 
the night, on ship-board and in camps. Even in jails, and the 
manufacturing towns, the night air is oftentimes one of the 
exciting causes of typhus fever. When the contagion may 
exist in the body, it is readily thus excited into operation by 
such change of temperature. Coming out of a heated atmo- 
sphere, after excessive exercise, as dancing or fencing, the body 
being previously heated by riding or running, and then suddenly 
cooled in a stream of cool air, by draughts of cold water, by 
throwing off our clothing, and by exposure of the body to a 
cooler atmosphere, or a cold bath — fever, in such case, is readily 
excited. 

While I had the direction of the botanical garden, I suffered 



EXCITING CAUSES OF FEVER. 149 

several very severe attacks of sore throat, that were thus in- 
duced by exposure to the cold air, after remaining some time 
in the heated air of the hot-house ; for the circulation being 
excited by the causes mentioned, the excretion by the skin flow- 
ing and increased, a sudden change of temperature instantly 
produces a check of that discharge, by creating a preter- 
natural constriction of the small excreting vessels of the sur- 
face, and of the smaller circulating arteries. The conse- 
quence is, a sudden resistance to the propelling power of the 
heart and larger vessels. A sudden plethora of them is neces- 
sarily the result, which vents itself in a general fever, and per- 
haps the affection of some irritable part of the body. These I 
call the stimulant, not the sedative, effects of cold. These 
stimulant effects, too, are increased by the new impulse which 
is given to the circulation by the crowded state of the heart, 
and of the larger vessels — analogous to the mechanical effects 
of the tourniquet, when applied before or during the cold stage 
of fever, to prevent or shorten the paroxysm of an intermittent, 
as recommended and practised by Dr. Kellie. See Duncan's 
Commentaries, vol. xix. 



14 



150 



LECTURE XIL 



CAUSES OF F E V E R, — C OLD. 



We also observe the stimulant effects of cold, when applied 
for the purpose of arresting hemorrhages, as in menorrhagia, or 
in. the hemorrhage after parturition, when the womb does not 
go on to contraction. A glass of cold w T ater given to the 
patient will bring on its action, and expel the placenta. And 
lately the practice of injecting the placenta through the vessels 
of the cord, with cold water, has been recommended for the 
same purpose, and used with success, Here let me say, that 
it is not necessary for this purpose, as recommended by Burns,. 
to stuff or plug the vagina, as he expresses it ; for you are to 
recollect you are not plugging an inanimate tube ; you are 
acting upon a very sensible part of the body. The application 
of cold to the pubes, or to the abdomen, is veiy generally 
sufficient, with other remedies addressed to the whole system. 
In epistaxis, cold is not applied to the bleeding vessel itself. 
Even prejudice at this day, the result of past experience, makes 
the application to a distant but sensible part of the body. In 
some countries, the great church key is sent for, and applied 
to the back of the neck, and is believed to possess some pecu- 
liar virtues ; though any other cold body would be equally 
efficacious. A cloth dipped in cold water, or a snowball, ap- 
plied to the scrotum, is also sometimes had recourse to, with 
success. These facts are familiarly known : the principle, too, 
upon which these remedies operate, is apparent. We see the 
stimulant effects of cold air, in arresting hemorrhage, after 
capital operations.* It is a good rule in operations to expose 

* See ray letter to Dr, Bard on this subject. 



CAUSES OF FEVER. 151 

the wound to the air, until the circulation is restored. This, 
in my opinion, is not sufficiently appreciated. Cooper himself 
seems to think lightly of it. But surgeons would have less 
frequently to open newly dressed wounds, did they more gene- 
rally adopt it. I once extirpated the whole breast in a young 
lady, without using a single ligature. The hemorrhage was 
arrested by the exposure of the wounded surface to the air for 
some fifteen or twenty minutes. 

The stimulant and tonic effects of cold, are also observable 
in its counteracting the relaxation which frequently occurs in 
the system, both local and general. We see it in the removal 
of relaxations of the scrotum, of the cremaster muscles, and 
of the spermatic veins. Debility in all of these organs is a 
disease of frequent occurrence, especially in warm climates, 
and in the warm seasons of temperate climates ; it is, too, an 
important disease, for by its continuance, it is w^ell known that 
the power of the genitals is very much impaired. Indeed the 
vigour of those organs, we know, very much depends upon 
the tone and condition of these appendages. Although this 
disease has no place in our nosologies, it is very well known 
in the West Indies, and in southern climates. I allude to the 
disease vulgarly called the ivhiffles. In cold climates, and in 
cold seasons of our climate, this relaxation is not known, but 
which ought to be the case upon the principle that cold is a 
sedative, and debilitating to the body. This disease is cured 
by the application of cold water to the parts concerned, night 
and morning, or by a general cold bath, and other tonics, 
where the whole system is at the same time greatly debilitated. 
If the relaxation be very considerable, a suspensory bandage 
may also be employed with benefit, as an auxiliary in sustain- 
ing the debilitated organs. 

The veins of the testes, like the hemorrhoidal, become re- 
laxed, especially by age, when the venous system in general 
becomes enlarged from the diminished resistance in the coats 
of the veins. A similar varicose enlargement of the veins takes 
place in the lower extremities, both in males and females — 
more frequently, however, in the latter, the consequence of 
some previous pressure upon them, or impediment to the pass- 
age of blood in them, occasioned by pregnancy. I have seen 
a case of varicose enlargement of the veins of the lower extre- 



152 LECTURE XII. 

mities, occasioned by a truss applied for a supposed hernia, 
which proved to be a varicocele. I also saw a case, in which 
the same disease was produced without any apparent cause. 
In both of these cases, a flannel roller and cold applications, 
either of spirits or water, and in summer the cold bath, are the 
remedies proper to be employed. The remedy now used in 
France, is to remove a portion of the vein thus affected, and 
afterwards pressure to facilitate the union of the parts from 
whence the excision may have been taken. 

In fluor albus, a disease frequently occasioned by debility, 
cold washing, and even cold injections into the vagina, are 
among the most valuable remedies that can be prescribed. 
Accordingly, the women of France, compared with American 
females, are seldom affected with fluor albus, owing to their 
daily use of the bidet. Here, however, let me caution you, on 
account of the stimulant operation of cold, against the use, or 
rather the abuse of it, during menstruation ; in obstruction of 
the menses; and in that species of fluor albus which proceeds 
from the fulness of the uterus, and of the whole system, the 
effect of the natural cessation of the menses — in other words, 
the effect of plethora, general and local, which is aggravated 
by cold, and is only to be relieved by venesection and other eva- 
cuants of the blood-vessels. In like manner, where the uterus, 
in consequence of such obstruction, is affected with pain, and 
other symptoms of inflammation, cold applications invariably 
aggravate the symptoms. 

The stimulant effects of cold suddenly applied to the system, 
are also apparent in the recovery of persons from deliquium, 
and in the asphyxia of new-born infants. And in asphyxia from 
the fumes of charcoal, it is one of the most efficacious reme- 
dies that can be employed. 

When dogs, at the Grotto del Cani, have been suffocated by 
its vapour, it is a common practice to plunge them in the ad- 
joining lake (Lake Avernus) to recover them. In like manner, 
in the torpor attendant upon convulsions, when weaker stimuli 
fail, the sudden affusion of cold water on the naked body will 
excite and increase sensation that has been dormant. In the 
convulsions attendant upon pregnancy or parturition, and which 
are frequently repeated in paroxysms, sprinkling the face and 
other sensible parts with cold water, frequently interrupts the 



CAUSES OF FEVER. 153 

return of the convulsions, by the new impression that cold 
water thus applied produces upon the whole system. 

" The stimulant action of cold," says Dr. Currie, " though 
short in duration, is powerful in degree. 5 ' Nor is its effect 
short in duration, as Dr. Currie supposes ; for the cold bath is 
certainly one of the most powerful tonics of the materia me- 
dica, and one of the most permanent stimulants in its effects 
upon the system. 

We also see the tonic and stimulant operation of cold in the 
effects of a general cold bath, and the application of cold air. 
Such is the contractile operation of cold on the smaller ves- 
sels, that the very first effect is, in some cases, to produce a 
momentary paleness ; the excitement, however, instantly suc- 
ceeds, the whole surface glows with blood and heat, the circu- 
lation is manifestly excited, and preternaturally so. Respiration 
is proportionally quickened, and succeeded by a general diffu- 
sion of heat throughout the body. If, however, it be applied 
to the enfeebled body, and continued any length of time, it 
exhausts the excitement by abstracting the caloric, and with it 
the remains of heat and life. But to the body in health and 
previously heated, it is powerfully stimulant. By washing the 
body when thus heated, and the sweat is flowing from the 
surface, erysipelas, rheumatism, pains in the back and limbs, 
are freqently produced. Even washing the neck with cold 
water in cynanche tonsillaris, aggravates the disease, by in- 
creasing the excitement, as I have several times experienced 
in myself. Gargling the throat, I must tell you, though a very 
common practice, has the same effect of increasing the irrita- 
tion in that disease. I have also witnessed the same injurious 
effects from the application of cold, in increasing the inflam- 
mation attendant on dysentery. 

The same remark is no less applicable in enteritis, from 
whatever cause it may be produced. Though I perceive the 
application of cold water to the belly is sanctioned by Dr. 
Thomas, I must here most earnestly enter my protest against 
this practice in that disease, or indeed in any disease attended 
with active inflammation. I go still farther : the application 
of cold to an inflamed eye, to an inflamed testicle, to the re- 
cent injury of the joints from strains, I consider equally objec- 
tionable. On the contrary, the relaxing, soothing, -and emol- 
14* 



154 LECTURE XII. 

Kent effects of tepid applications, are indicated in the first stage 
of those diseases of excitement. I tell you this as the result of 
nearly forty years' experience in practice. But the beneficial 
operation of cold bathing, general and local, in the last stage of 
those diseases, is well established, except when the debility is 
excessive, and the heat-generating power of the system has 
been greatly impaired. Habit, however, may counteract the 
effects of cold upon the system. Accordingly, in Russia, it is 
not unusual to go from apartments highly heated, or from a 
bath heated from 106° to 116° of Fahrenheit, and plunge into 
snow or cold water, at the freezing point, without producing 
fever. 

The Roman youth, when heated by their exercises in the 
Campus Martius, in like manner plunged into the Tiber with 
impunity. 

The previous excitement, especially in athletic habits, is 
such as instantly by its reaction to counteract any check given 
to the action of the smaller vessels of the surface. Habit cer- 
tainly may diminish our susceptibility to the effects of cold, as 
of other agents upon the constitution. We do not all take the 
small-pox when exposed to it. We do not all take contagious 
fevers, as yellow fever or dysentery, though we may be ex- 
posed to them. Physicians and nurses, habituated to the action 
of the poison producing diseases, frequently escape on this 
account. Nor do we all take cold even from wet feet ; but 
where persons are much in the practice of bathing the feet in 
warm water, this is not an unusual effect of the great sensi- 
bility that is thus endured. 

I was formerly subject to frequent attacks of sore throat, and 
at that time was in the habit of bathing my feet in warm water 
two or three times a week. But since I have adopted the 
practice of washing exclusively with cold water, I have rarely 
been affected with the disease. Many persons subject to cold 
feet and legs, are thus cured by the application of cold water. 
Frosted heels are in like manner prevented, by the practice of 
cold washing, as well as by the local use of spirits of turpen- 
tine, alcohol, or other stimulants. 

Sudden vicissitudes produce fever, as going from a warmer 
to a colder atmosphere. In the interior of Africa, it is not 
uncommon for the temperature of the atmosphere to be, for 



CAUSES OF FEVER. 155 

weeks together, as high as 130° of Fahrenheit. In such case, 
the sudden change down to 100°, as Dr. Fordyce believes, 
would doubtless, as a stimulant, constrict the extreme vessels, 
both exhalent and circulating, and fever be the consequence. 
But he states, that he has known going from 100° to 80°, and 
even the transition from 60° to 40°, to produce fever, (p. 134,) 
and which, by the by, is another example of the effects of cold 
in producing diseases of excitement. In other words, that cold 
under peculiar circumstances, and those chiefly depending on 
the state of the nervous system, operates as a powerful stimu- 
lant or excitant to the system.* 

They show the direct stimulant effects of cold water and ice 
applied to the limbs. Another important result arrived at from 
those experiments is, that the arteries derive their power of ac- 
tion from the nerves with which they are supplied, and not 
from a separate vis insita, or inherent irritability. 

* Experiments of Dr. Home — see Eng. Journal, No. 4. vol, iv. 



156 



LECTURE XIII. 



CAUSES OF FEVER 



We have noticed the stimulant, as well as the sedative ope- 
ration of cold, and endeavoured to show that these different 
and even opposite effects are produced by it, depending on the 
manner in which cold is applied to the body, the medium through 
which it is applied, whether by air or by denser bodies, as 
water or mercury, the temperature of that medium, the dura- 
tion of its application, the suddenness with which it is applied, 
the state of the nervous system, and the vigour of the circula- 
tion, or of the power generating and diffusing the heat of the 
body. 

In the conclusion of the last discourse, I also stated, that 
sudden changes from a higher to a lower temperature, as ob- 
served by Dr. Fordyce, expose the body to diseases of excite- 
ment ; that they not only render the body liable to fever, but 
to many other diseases of a febrile character. 

Dr. Fordyce admits the fact that fevers — that is, fevers 
strictly so called, are of more frequent occurrence in warm 
than in cold climates ; but he ascribes it to the sudden diminu- 
tion of temperature as the cause, at the time when the body 
is exposed to a high temperature ; that is, that in a very hot 
climate, exposure to cold or night air produces fever; whereas 
in a temperate climate, such exposure to cold would not pro- 
duce fevers, but perhaps one of the phlegmasia ; and, there- 
fore, that the cause of these different effects, is to be looked 
for in the high thermometrical range which occurs in hot lati- 
tudes. But great heat or excitement of itself, acting upon the 
stranger, doubtless, as before remarked, will directly produce 
fever, without such vicissitude. Yet from cold, as dews and 
the night air, this effect is certainly more likely to happen. 



CAUSES OF FEVER. 157 

But this more frequent occurrence of fevers in hot climates, 
is probably in part owing, not merely to the vicissitudes in a 
high thermometrical range, as Fordyce expresses it, but to the 
long-continued previous effects of heat upon the constitution, 
changing the condition of the body, of the fluids as well as the 
solids, at the same time that the sensibility to impression in the 
nervous system is increased by the debilitating effects of heat. 

In cold climates, again, we see catarrh, pneumonia, and the 
phlegmasia?, in general produced; and in cold climates there is 
certainly no such predisposition to fevers, properly so called, 
compared with the predisposition we find in hot climates ; — no 
such septic tendency of the fluids of the body, nor such debility 
and consequent irritability of the nervous fibre, both of which 
have effect in a hot climate, as predisposing causes of fever. 

This, I believe, is the true reason of that difference of pre- 
disposition, and not that assigned by Dr. Fordyce, who (p. 135, 
vol. i.) considers merely the higher temperature of the climate 
in which those transitions take place, as having the effect, 
without explaining the manner in which that temperature ope- 
rates. " As to the manner," he says, " it is not attempted to 
be explained." But, in my opinion, the manner of its opera- 
tion is very apparent, and in the way already stated, viz., 
by producing a debilitated habit of body. And it is to be ob- 
served, that intemperance and excesses of different sorts, very 
generally concur with the heat of the climate, in producing 
such debility — an irritable, susceptible state of the whole sys- 
tem, is the inevitable consequence, followed by a deranged 
state of the digestive organs, and of the whole alimentary 
canal, and consequently an altered or deranged condition of 
the whole mass of the circulating fluids — for an imperfect or 
bad chyle cannot produce perfect or healthy blood. And to 
these is added, a disturbed state of most of the secreting and 
excreting organs of the whole system. All fevers and febrile 
diseases must hence, necessarily, have a greater tendency to 
the typhoid character, in a hot and relaxing, than in a cold and 
invigorating climate, unless we totally exclude the fluids from 
all concern in the human body, and from all participation in 
its diseases — and, indeed, the solids too ; for if the secretory 
organs of the body are deranged, such derangement of the 
fluids, the product of the secretions, must necessarily be de- 



158 LECTURE XIII. 

ranged also. And vice versa, if the fluids are affected, the 
solids secreting and influencing the character and properties of 
such fluids, must also themselves have been in some degree 
deranged or impaired, to produce such condition of the hu- 
mours they convey or secrete. 

We also witness a similar predisposition to fevers, in the hot 
seasons of our own climate, and indeed in the hot seasons of 
most temperate latitudes. Besides, where cold, in a hot cli • 
mate, or in the hot season of temperate climates, is the exciting 
cause of fever, the heat of such climate and of such season, 
operating upon the constitution, before the application of cold, 
the nerves and blood-vessels, I say, all being previously ex- 
cited, and the secretion flowing, the result of that impetus 
given to the vascular system, cold in that case, has assuredly 
more effect than it could otherwise produce, without such 
predisposition. Cold, then, arrests all these excretions and ex- 
halations, diminishes very suddenly the flow to the surface, 
and in this way excites the whole system into febrile action. 
This leads me to notice what I consider to be another error of 
that great practical physician, Dr. Fordyce, see p. 136, vol. i. 
He observes, that cold suddenly applied, and cold slowly or 
gradually applied, have the same effect ! He grants that, in 
both cases, cold acts by restraining the evaporation from the 
surface, and by contracting the exterior vessels. Yet, in the 
one case, he asserts that when cold is suddenly applied, fever 
is produced ; in the other, not fever, but some other disease. 
He further observes, that the gradual diminution of temperature 
has never been observed to produce fever, and therefore con- 
cludes, that such fever cannot be the operation of cold. I 
grant this fact, that the gradual changes from heat to cold 
will not produce fever ; and I will grant another fact connected 
with it, that by going from a cold climate to a warm one, in the 
winter season — or, in other words, gradually changing our tem- 
perature, we do not readily take the fevers of a hot climate ; 
i. e. not as arising from the climate itself. But I deny his pre- 
mises, that the sudden change and the gradual are alike in 
their effects ; and, of course, I deny the conclusion he has de- 
duced from those premises. His conclusion is as follows : — 
" That, therefore, fever does not arise from mere contraction 
of the extreme vessels, the diminution of vapour rising from 



CAUSES OF FEVER. 159 

the body, or the diminution of the exudation from the skin; as 
these are," he says, " alike produced from the sudden and gra- 
dual exposure to cold !" 

On the contrary, the effects are very different, for in the 
one case a sudden check is given both to the small circulating 
and the exhalent vessels, and thereby an instantaneous and 
powerful impulse is given to the heart and larger vessels, which, 
in their reaction, manifest great and increased excitement 
throughout the whole system. As in the febrile excitement 
produced in those cases which so frequently occur from the 
use of cold water, when the body has been previously excited 
by heat and spirituous liquors. At first, there is a shock of the 
nervous system, then excitement of the vascular, producing an 
engorgement of the brain, &c. In other words, fever is the 
consequence ; but this is not the case where cold is gradually 
applied. 

Nothing is more commonly known, even in this climate, than 
the fact that plunging into the river, when the body is heated, is 
an exciting cause of fever; exposure under similar circumstances 
to a shower of rain, operates in the same way. In every hot 
season, facts of this nature present themselves to the practi- 
tioner in this city, showing the effects of a sudden check to 
the discharges which so usually occur in such season, espe- 
cially when an additional impulse is given to the circulation by 
exercise. Yet he considers his reply as furnishing an ample re- 
futation of the doctrine he opposes, when he says, " that cold 
operates by its contraction and obstruction of the extreme 
vessels, whether suddenly or gradually applied ; and that, as 
fever in the latter case is not produced, so it is not in the for- 
mer !" 

To my mind, the explanation here given, appears more sa- 
tisfactory, viz. that the body being previously excited, the 
sudden exposure and change of temperature, account for the 
phenomena produced. 

Dr. Fordyce also observes, that the effect of sudden expo- 
sure to cold, is to produce other diseases, but not fever; and 
that one hundred other diseases, as the phlegmasia?, are pro- 
duced for one of fever by that cause ! This may be, and pro- 
bably is true, in a cold climate, but it certainly is not true in 
a hot one. 



160 LECTURE XIII. 

Again, he remarks : " If a man when fatigued is suddenly 
exposed to cold, the exposure is much more frequently follow- 
ed by disease, and particularly by fever," p. 138 ; and adds, 
by way of illustration, "if a man has been in a crowded assem- 
bly, where his attention has been strongly excited, and comes 
suddenly out into the cold air ; or if he has been fatigued by 
exercise, if he should throw himself into cold water, there are 
many instances of fever having immediately ensued." Here, 
then, he admits the effects of cold suddenly applied, producing 
fever ; but qualifies it by premising fatigue, dancing, or other 
exercise, to put the body in a state to be acted upon by cold, 
to produce fever. I ask, where is the difference between the 
excitement given to the system by fatigue, or by exercise, and 
that communicated by the climate ? You will all answer — 
certainly none. 

This question answered, I again ask, is it not more conso- 
nant with facts and correct reasoning, to say, 1st, that in a 
cold climate, when the body is heated by exercise, by intem- 
perance, or any other cause, and then suddenly exposed to 
cold, fever, and especially the phlegmasia?, are produced. 
That in a hot climate, such sudden exposure, in the habit of 
body debilitated by the heat of climate, and other causes, 
will generally produce fever ; and again, that where the habit 
is vitiated, in other words, a putrescent tendency of the fluids 
exists, as from bad diet, impure air, and other causes, it will 
produce fever that readily assumes the typhoid character. In 
the one case, the effect produced may be considered in some 
degree as merely a mechanical check or interruption to the 
discharges of the body; I mean the effect of cold in pro- 
ducing the phlegmasia?. But in the other case, where the 
fluids of the body have a septic tendency from climate, diet, 
or any other cause, a chemical action is united with, or added 
to, the constriction of the vessels, to produce the more com- 
pound effects upon the system, viz. typhus fever. Such, at 
least, is the conclusion I have been led to upon this subject, 
after a very careful examination of the facts, and the most 
correct reasoning I can bestow upon them. 

I also observe, that upon the sudden application of cold to 
the body in producing fever or febrile diseases, such is the 
connexion of nerves throughout our machine, that it is not ne- 



CAUSES OF FEVER. 161 

cessary that the whole surface of the body be exposed to the 
action of cold. A snowball, or a cake of ice, applied to the 
scrotum, we know by the constriction it produces, will check 
a bleeding vessel of the nose. Cold, in like manner, applied to 
the feet, will excite the action of the bowels, by checking the 
flow of fluids to the surface of the body ; and in this way, we 
know that obstinate constipation of the bowels has been, in 
some cases, cured. See Med. Essays of Edinburgh. So, in 
like manner, will a partial stream of air, received upon the 
neck, or poured into the lungs, produce either one of the phleg- 
masise, or a fever, according to the circumstances of climate, 
or the condition of body. 

4th. Moisture is an exciting cause of fever. A moist atmo- 
sphere, we know, predisposes to inflammatory diseases, as 
croup, pneumonia, and phthisis, by its action more especially 
upon those organs which are the seat of those diseases. But 
how does moisture operate, as an exciting cause, in producing 
fever ? Both by relaxing the whole system, and by abstracting 
our caloric. And as our heat is constantly carried out by our 
secretions, as a vehicle, and still more abundantly by the con- 
version of that fluid into vapour, by which the temperature is 
diminished ; so moisture, when constantly applied to our bodies, 
in a similar manner abstracts our caloric and reduces our 
temperature, and with it impairs the functions of the system. 
As it regards its operation upon the body, moisture may be re- 
solved into cold, for it produces the same effects : for, by the 
application of moisture to our bodies, we lose our heat in the 
same manner as it is carried off by the fluid of perspiration 
or sweat. 

Fordyce does not appear to understand this subject. In page 
148 he observes, that the operation of moisture on our system 
is not very clear : — to him it certainly is not, for chemistry 
never received from him that attention which should be given 
to that highly interesting branch of science by every physician. 

As I have already remarked, the fact is familiarly known, 
that evaporation produces cold, agreeably to the first law go- 
verning the communication of heat, viz. that all bodies pass- 
ing from a denser to a rarer state, absorb caloric, as illustrated 
by Dr. Cullen, in his excellent paper on cold. As before re- 
marked, we observe its effects in the process of cooling liquors 
15 



162 LECTURE XIII. 

in a hot climate, by means of evaporation. We experience it 
in cooling the air of a house, by wetting the floors ; and the 
same effects are observed in the change produced in the tem- 
perature of the air after a shower of rain. 

In like manner, our heat is carried off by moisture, both as 
applied to our bodies, and flowing from the surface by perspi- 
ration. Indeed, this discharge being excessive, even cold 
sweats, as they are denominated, are produced ; for we fre- 
quently find the perspiration out of all proportion to the previ- 
ous excitement of the arterial system, and entirely the conse- 
quence of a relaxed, exhausted state of body, and of course 
a relaxed condition of the excreting vessels. Under these cir- 
cumstances, the stimulus so necessary to health being with- 
drawn, (even though gradually withdrawn,) great exhaustion 
and debility follow — sometimes death itself. But the effect of 
the sudden and temporary application of cold to the body is 
exciting to the system, especially if in the vigour of health. 
Not so the continued application of cold or moisture. Standing 
immersed in water — remaining in wet clothes, or clothes put 
on wet or damp — sleeping in damp sheets — a wet greatcoat, 
even though the body be covered with dry clothes underneath, 
— all these chill us, by abstracting our heat, and thereby 
arresting the circulation in the smaller vessels. We hence 
see the propriety, when not in exercise, of throwing off our 
greatcoats when wet, even though we may have dry clothes 
beneath. Although w 7 e may, by the non-conducting media of 
cotton or flannel, guard ourselves, under ordinary circum- 
stances, yet these are not always sufficient to prevent the ab- 
straction of our heat ; such is its ready union with moisture, 
its natural conductor. Cold and moisture in this manner, and 
in a septic state of body, become an exciting cause of scurvy. 
Otherwise, even though the system be affected by the diet, ex- 
ercise, and warmth, it will frequently escape that disease; — not 
so when idle, and lodged in a damp and cold atmosphere. See 
Capt., Parry's Voyage. According, then, to our condition of 
body as to strength, and the power of restoring the circula- 
tion, and with it the heat, and thence the power of resisting 
disease ; and according to our predisposition at the time — in- 
flammatory complaints, such as rheumatism, and the various 
forms of cynanche and pneumonia, are, or are not produced. 



CAUSES OF FEVER. 163 

In like manner, depending upon the state of our fluids in con- 
nexion with the debility of body, from fatigue and intemperance, 
fevers of a mild or a malignant character are produced. The 
Walcheren fever, (see the account of it given by Davis,) 
which cut off so many of the British troops in the summer and 
autumn of 1809, and which occasioned the failure of the ex- 
pedition to Zealand, was thus engendered by these combined 
causes — the moisture, miasma, influence of season, intemper- 
ance, bad diet, and other circumstances usually met with in 
large armies. 

The malignant fevers of Flanders, the Netherlands, (Hol- 
land,) and the malignant fevers of Batavia, are also in the same 
manner to be accounted for. Batavia, in a remarkable degree, 
unites both moisture and miasma ; for the Dutch, by cutting 
canals through it, have made another Holland of it. Indeed, in 
consequence of this union of moisture and miasma, Batavia is 
more unhealthy than Holland. The greater heat of Batavia, 
too, is another predisposing cause of the more violent and fatal 
fevers of that country. So, in like manner, the fens of Lincoln- 
shire, and indeed the marshes of all countries, are unwhole- 
some, in consequence of this noxious union of miasma with 
moisture; while the banks of the Thames, or the Seine, are 
comparatively healthy. Hence, too, the fact that running wa- 
ter, sea water, and river water, (which emit no miasmata,) are 
less injurious than the water of stagnant pools or marshes. 

A fact illustrative of this distinction was communicated to 
me some time since, as occurring during the last war. Three 
hundred sea-fencibles were stationed at Fort Diamond, at the 
Narrows, two or three hundred yards from the shore. Al- 
though not exposed to moisture from the soil itself, yet the bar- 
racks were so bad that they were drenched by every shower 
of rain. They enjoyed good health, and were free from fever ; 
not a man died in five months. Here they were exposed to mois- 
ture alone. In October and November, 1814, a brigade of troops 
were stationed at New Utrecht, some in barracks, others in 
tents ; but both in the excavation of a hill, that afforded a large 
receptacle for the rain that fell. These troops, in consequence 
of this lodgment of rain, became the subjects of typhus fever, 
and a considerable number were destroyed. Again : a company 



164 LECTURE XIII. 

of riflemen was also stationed in the sandy beech below, in bar- 
racks, situated at the bottom of a high bank. Among these, 
only two or three cases occurred, but none of which proved 
fatal. No lodgment here took place either of rain or moisture 
from below, for the sandy bottom readily conveyed it off as 
fast as it fell. 

Similar facts are stated by Sir James Fellowes, in his work 
on the Walcheren fever. He remarks, that many cases of fever 
were induced by the men remaining out in the evening air, 
smoking their pipes under the trees, with their bodies frequently 
exposed by taking off a part of their dress ; while others - more 
prudent were sheltered, and remained in health, p. 343. He 
also states, that the practice of taking out the- troops to exer- 
cise before sunrise, was attended with fatal consequences, from 
exposure to the damp and noxious exhalations. 

But, as I have before observed, fevers are, in some instances, 
produced by moisture alone. During the war which took place 
in Flanders, between 1710 and 1711, an army was encamped 
upon sandy ground, in which water was found in digging less 
than a foot deep. Upon digging the wells the air immediately 
became loaded with moisture, and in a few days fevers were 
produced in great numbers, although the army was healthy be- 
fore; and upon changing their grounds (see Fordyce, p. 147,) 
no more fevers were produced. The predisposition to fevers, 
in such case, was to be presumed as existing among the soldiers. 
Moisture, abstracting their heat, would not only debilitate them, 
but would necessarily produce a similar constriction upon the 
exhalent and small circulating arteries, which we have noticed 
from cold when directly applied to the body. 

I have seen the same effects occasioned by moisture in the 
state prison, after wetting the floors, which was done once a 
week, and without removing the prisoners from the apartment 
while this process was performed. The consequences were, 
remitting fevers, the phlegmasia?, and, in some instances, diar- 
rhoea — analogous to the effect of throwing cold water upon the 
extremities in cases of constipation of the bowels. In the 
same manner, rock-blowers and well-diggers, being constantly 
immersed in water, are affected with rheumatism ; and a com- 
pound of palsy and rheumatism of the lower extremities, called 



CAUSES OF FEVER. 165 

berbiers; so called on account of their hobbling gait, resem- 
bling the motion of a sheep. 

5th. Another exciting cause of fever is our food. It may 
prove so in various ways. — 1. Food may be an exciting cause 
of fever, as it is of nervous affections, from being indigestible. 
In this case it may create, by its operation upon the stomach 
and intestines, considerable excitement throughout the system, 
that is otherwise predisposed to fever. 2. The excessive use 
of animal food, in a hot climate, or in hot seasons of the year, 
produces a putrid state of the bowels. In this way not only 
dysentery is produced, but by the operation of that food the 
whole mass of fluids becoming tainted, other fevers of a ma- 
lignant character are the consequences. Fish, oysters, eggs, as 
well as other animal food, may thus become the exciting causes 
of fever, as they readily run into the putrefactive fermen- 
tation. Animal food, too, in like manner, becomes an exciting 
cause of a relapse, when too early employed during convales- 
cence from fever, especially the typhus form. Of the malig- 
nancy of the fluids, occasioned by the excessive use of salted 
animal food, we have already spoken; particularly as pro- 
ducing a scorbutic state of body, and thereby especially predis- 
posing the body to malignant fevers. 

6th. Another exciting cause of fever is, concentrated human 
effluvia. Even in the individual, neglect of the bowels, in the 
summer season, creates a febricula, manifesting itself by the 
furred tongue, hot hands, burning feet, thirst, headache, and a 
frequency of circulation. These neglected and long continued, 
are soon followed by a more formidable attack of fever. In 
this way dysentery and typhus fever are frequently engendered 
in the individual, as well as in the congregation of a great 
number of individuals, as in a jail, a ship, or a hospital. In 
the latter cases, the excretions of the surface, and some others 
still more offensive, are not unfrequently additional sources of 
filth, and thereby become the exciting causes of fevers. In the 
individual, too, in whom an obstructed liver exists, typhus fe- 
ver is frequently engendered by the obstruction of the bowels, 
from the want of the natural cathartic. 

7th. The passions of the mind are among the exciting causes 
of fever. Case of Mr. B — — G. ; — he had an intermittent — 
15* 



166 LECTURE XIII. 

was free from it — he lost a great quantity of blood from the 
nose ; the fever was not renewed by this hemorrhage, nor 
did a diarrhoea afterwards renew it ; but his mind becoming 
agitated by the sufferings and pain, and the screams, of his bro- 
ther during an operation, immediately renewed his fever, by the 
irritation it communicated to his nervous system. This shows 
that irritation, and not debility, is the source of fever : other- 
wise, his exhaustion from hemorrhage and diarrhoea would 
certainly have renewed it. 



167 



LECTURE XIV. 



CAUSES OF FEVER.— MIASMA AND CONTAGION, 



The eighth exciting cause of fever, is the miasma of 
marshes. 

Marsh miasma produces both intermitting and remitting 
fevers, depending upon the condition of body, the nature of 
the climate, season of the year, and the quantity or degree of 
concentration in the miasma. In the most healthy seasons in 
the island of Jamaica, and the other West India islands, inter- 
mittents are produced. Again, as the season is hot, there is 
a tendency to the continued form of fever, or to a less perfect 
intermission. In winter, again, the intermittent character re- 
turns. 

It is certainly very extraordinary, that although the insalu- 
brity of swamps and stagnant waters was well known, and was 
noticed even by Hippocrates, Galen, Varro, Columella, Palla- 
dius, Vitruvius, Diodorus Siculus, Dionysius Hallicarnassensis, 
Strabo, and others, Sydenham should not have known or 
suspected that intermittents or remittents arose from marsh 
miasmata. He acknowledges he tried in vain to find out 
why seasons, apparently similar, should have such dissimilar 
effects on the human frame. Yet so it is, he says : " Ita enim 
se res habet ;" and adds, " variae sunt nempe annorum consti- 
tutiones, quae neque calori, neque frigori, non sicco humidoque 
ortum suum debent, sed ab occulta potius et inexplicabili 
quadem alteratione in ipsis terras visceribus pendent, unde aer 
ejusmodi affluviis contaminatur, humana corpora huic aut 
illi morbo addicunt determinantque." De Morb. Epidem. c. 
ii. p. 41. 



168 LECTURE XIV. 

In these various effects, you perceive an operation analogous 
to the effects of cold air in cold climates and cold seasons, 
producing the phlegmasia? ; — and of the dews and cold night 
air in hot climates and hot seasons, producing fevers ; while 
the same, causes in a vitiated habit of body produce typhoid 
or malignant fevers. 

Lancisi, who lived from about the middle of the seven- 
teenth century to the beginning of the eighteenth, (he died in 
1720,) was one of the first accurate observers on the subject of 
marsh miasma.* In the Med. and Phil. Register, vol. i., you 
will find a faithful translation of his valuable work, by the late 
Lieutenant Governor Colden, who was a learned physician. In 
Bruce's Travels, you will also see an account of the disease 
produced by the same effluvia, when exhaled from the mud and 
marsh left by the waters of the Nile after the inundation. The 
remittent fevers of Bussorah are in like manner induced after 
the inundation occasioned by the Euphrates. Indeed, in some 
cases its banks have been intentionally destroyed by the Arabs, 
in their hostility to the Turks of Bussorah. The deserts in the 
neighbourhood being overflowed, stagnant water is the result, 
filled with putrid fish, and decomposed animal and vegetable 
matters of various kinds ; the effluvia from these produce remit- 
ting fevers of the most malignant type. Twelve or fourteen 
thousand inhabitants have been thus swept off by the fevers 
occasioned by a single inundation in that hot country. For an 
account of the Bussorah fevers, see Transactions of the Medical 
and Chirurgical Society for 1793. See also Wilson, vol. i. p. 84. 
In the 2d vol. p. 192, lately published of the same Transac- 
tions, you will also find an interesting description of a similar 
malignant remittent occurring in Portugal ; and of the fever of 
the East Indies, or jungle fever, as it is called. 

Miasma in our own climate, and in all temperate latitudes, 
exists most abundantly in the autumn. The system is then 
more disposed to be acted upon, the habit of body being at that 

* Lancisi (de nox. paludum effluv.) He gives a remarkable instance of the 
hurtful quality of the air of putrid marshes. Thirty gentlemen and ladies, of 
the first rank in Rome, had been sailing upon a party of pleasure, towards the 
mouth of the Tiber. Upon the wind suddenly shifting and blowing south, over 
the putrid marshes, twenty-nine of the thirty were immediately seized with a 
tertian fever — one only escaping. 



CAUSES OF FEVER. 169 

time relaxed and debilitated, in consequence of the heat of the 
preceding summer : — and we may add that the body is also, by 
the action of the same causes, in a more vitiated state. Observe, 
that the vitiated habit gives malignancy to fevers, but not sus- 
ceptibility, or at least this is less certainly the case. And in- 
deed, upon some occasions, it would appear that the deleterious 
action of such vitiation upon the nervous system has a con- 
trary operation, that of rendering the system less liable to be 
acted upon by some of the exciting causes of fever, particularly 
contagion ; for the stranger is certainly more susceptible of yel- 
low fever than the native. We are at that time, therefore, as a 
consequence of the debility and relaxation occasioned by the 
summer's heat, more susceptible of the operation of the miasma 
of autumn. This predisposition, however, may be counteracted 
by generous living, but not by water-drinking or a vegetable 
diet, but by the moderate use of wine, and a due proportion 
of animal food. 

An illustration of this is afforded by the case of some friends 
of mine, living in Duchess county. Two of them are water- 
drinkers, and they frequently have the fever of that region. 
Two others, living in the same neighbourhood, who drink good 
old Madeira, have always escaped. 

In autumn, too, from the causes which have been mentioned, 
such is the predisposition, that the intermittent readily becomes 
a remittent, and the remittent not unfrequently assumes the 
typhoid character. Such was the case with one of the water- 
drinkers just referred to, in 1812. His disease began as an 
intermittent ; it soon became continued ; and finally ended in 
typhus. His nervous system became very much impaired, 
showing itself in his mind and body, for many months after 
an attack of fever thus induced. 

Miasma no doubt operates as a ferment upon our whole 
system, having its peculiar laws, like every other poison in- 
troduced. As marsh miasma is the result of the putrefaction of 
vegetable matter, Dr. Hugh Williamson, in his very interest- 
ing account of the fevers of North Carolina, contained in his 
history of that state, considers even the most simple species of 
intermittent as in some measure the effect of a putrefactive taint 
introduced into the system ; especially, as he observes, the most 
putrid fevers arise from the same cause ; that is, that in this 



170 LECTURE XIV. 

country the heat of the climate contributes to this effect by 
its predisposing action on our system. Hence, too, it happens 
that intermittents in this climate, in common with all hot lati- 
tudes, have a great tendency to assume the continued type, 
and thence to end in a typhoid state of the system. To the 
same cause it is owing, that even the inflammatory diseases of 
winter in that climate have the typhous tendency, and will 
scarcely admit of the lancet. Hence, too, the typhous termi- 
nation even of the intermittents of that country, as observed by 
Dr. Williamson. 

This leads us to inquire, what are the circumstances favour- 
able to the operation of marsh miasma? They are, 1st, mois- 
ture. — Troops occupying the lowest situations, have been always 
observed by army physicians to be most liable to the influence 
of miasma. In the island of St. Lucia, it has commonly been 
remarked, that when the garrison, in a lofty position, is healthy 
during the time of dry weather, the inhabitants of the town at 
the base of the same hill, immediately below, and within half 
cannon shot, are visited by the worst fevers. Medical and Chi- 
rurgical Transactions vol. viii. p. 132. Even the smallest emi- 
nences, by their relative dryness, though equally exposed to the 
miasma, are observed to afford some security against its 
effects. The ground floor of the same building or barrack, is 
more unhealthy than the upper apartments. Hence, too, as 
observed by Sir J= Pringle, the cottage is less healthy than the 
town. The same author, in illustration of this fact, states the 
situations of two battalions : one was in a town remarkably 
healthy ; while the other, in a cottage, was, in consequence of 
their comparatively damp situation, rendered very sickly. The 
same observations have been made by Dr. Brocklesby, by Dr. 
Donald Monro, and by most army physicians. " The lower 
and moister the camp or garrison, and the more moist the 
season, the more subject an army is to agues," says Monro. 
See Wilson, p. 85. We may add, that this usually arises in 
consequence of the debilitating effects of cold in this instance. 

The effluvia of marshes, it may also be observed, are worse, 
and more virulent in their effects, when the water is drained off. 
As at the Nile, fevers are not prevalent during the inundation, 
but afterwards become so ; at the same time that they are 
more malignant. The same thing was observed, after the 



CAUSES OF FEVER. 171 

overflowing of the Tiber. Baglivi, Op. Omn. p. 51, the great 
Roman physician, observes : " Certa Romanorum observatione 
constat, post ingentes Tyberis inundationes oriri febres epide- 
micas in urbe valde graves ac perniciosas." 

I have observed the same thing to occur at Newtown, Long 
Island ; that after the waters of the creek that puts up from the 
arm of the sea which passes between us and Long Island, 
improperly called the East River, has retired after an uncom- 
monly high tide, a great quantity of matter was left bare, from 
which an exhalation arose, loaded with the poison of a very 
formidable remittent and typhus fever. A similar observation 
has been made by Dr. Rollo, at St. Lucia. Intermittents oc- 
curred during the rains, but remittents after the waters were 
drained off. 

It is well observed by Melville, in his Experimental paper in 
the Edinburgh Literary Essays, " that light only communicates 
heat when its rays are obstructed, reflected, or refracted." 
This obstruction or reflection does not take place so readily 
when the ground is overflowed with water. The water being 
clear, will not become readily heated in such case, as the rays 
of the sun are not so readily reflected. Of course, the putre- 
factive process is less perfect and extensive, as the sun has not 
the same effects on the earth, the reflection of its rays being 
less powerful. 

But moisture alone will produce agues. They are fre- 
quent, says Dr. Moseley, in rainy seasons, when there is no 
miasma to produce them. " Agues," says Dr. Lind, " occur 
in the most healthy parts of Great Britain," i. e. from the 
moisture of the climate, without miasma. But it is by all ad- 
mitted, that they are certainly most frequent in the fenny coun- 
ties of England. Yet, though moisture favours the action of 
miasma and the putrefactive process that begets it, it is not 
essential to the production of fevers. For at Newtown, Long 
Island, and in most parts of this island, those diseases have 
existed — in seasons, too, of the greatest drought. I have known 
families residing on this island compelled to come to the city, 
in seasons remarkable for drought, on account of intermit- 
tents. 

In such cases, there appears to be still a peculiar effluvium 
exhaled from the soil, i. e. from ground that had been before 



172 LECTURE XIV. 

marshy — though dry, it will still exhale such effluvia, especially 
when acted upon by an inordinate degree of heat. A similar 
observation is made by Livy, lib. v., and by Baglivi, Op. 
Omnia, p. 157. Speaking of marsh miasma, (the malaria of 
the Italians,) he observes: " Pestilentia orta sit in agro Romano, 
ob siccitates et nimios solis calores." And we may observe, 
that in cases of great drought, there is also an early fall of the 
leaf. May not the decomposition, therefore, of those leaves, 
aid in the production of such effluvia ? 

According to Lind, ships at a considerable distance from a 
swampy shore escape, while those that are near, within a 
mile, suffer. The first have the moist fog, but the last have 
the peculiar miasma, combined with that moisture. Dr. Fran- 
cis informs me, that the crew and passengers of the ship he 
returned in during the month of August, (1816) all enjoyed 
good health, until they were exposed to the fogs on the banks 
of Newfoundland, where they had not only moisture, but the 
peculiar effluvia blended with it, that proceed from the soil, 
which in some of the banks is very near the surface. In 
like manner, Pringle states, that the men-of-war which lay at 
anchor in the channel, between South Beveland and Walche- 
ren, during the worst period of the distemper that prevailed 
among the British troops in 1747, were not affected with either 
flux or fever, but enjoyed the most perfect health. See also 
Davis on the Walcheren Fever, p. 15. 

But although miasma most generally produces intermittent 
and remittent fevers, and moisture may favour its operation, it 
is also very certain that the cause of those diseases is, in some 
instances, generated within the system, but perhaps called into 
action by fatigue, heat, cold, or moisture. Accordingly, in 
the city of New York, we have intermittents and remittents 
at all seasons, winter and summer, as well as in the spring 
and autumn. Dr. Willan also met with intermittents in persons 
residing in the most healthy parts of London. See his works, 
p. 167-8. Dr. Gregory makes a similar observation of their 
occurrence in elevated parts of Edinburgh, independently of 
any previous exposure to marsh miasmata. Dr. Bateman makes 
the same remark. See also Medical Facts and Observations, 
vol. vii. Three cases are noticed by Dr. Beddoes, as occurring 
at Bristol during a hard frost. 



CAUSES OF FEVER. 173 

Before I conclude these observations on the effects of moist 
and marshy situations, let me refer you to a very instructive 
document on this subject, as it regards their influence on health 
and life in general, independent of their agency in the more 
immediate production of fevers. This document you will find 
in the second volume of Dr. Price's celebrated work on Annui- 
ties and Lives, exhibiting the proofs of the insalubrity of 
marshy situations. He observes, (see vol. ii. p. 29,) that the 
probabilities of living are highest in the most hilly parts of the 
province, and lowest in the marshy parish, (the parish referred 
to is a part of the district of Vaud, in the Canton of Berne, in 
Switzerland, containing one hundred and sixty-nine families, 
and six hundred and ninety-six inhabitants.) One half of all 
born in the mountains, live to the age of forty-seven. One half 
of all born in the marshy parish, live to the age of twenty-five. 
One in twenty of all born on the hills, live to eighty. One in 
fifty-two only, in the marshy parish, reach eighty. In the hills, 
a person aged forty has a chance of eighty to one for living a 
year. In the marshy parish, his chance is not thirty to one, 
for living a year. In the hills, persons aged twenty, thirty, and 
forty, have an even chance for living forty-one, thirty-three, 
and twenty-five years respectively. In the fenny parish, per- 
sons at those ages have an even chance of living only thirty, 
twenty-three, and fifteen years. See also Priestley's Observa- 
tions on Stagnant Waters, in the Royal Society's Transactions 
for 1774. Also, Murat's Observations, published in the Me- 
moirs for 1766 of the Economical Society at Berne. See also 
Simond's Travels, vol. i. 

2d. Besides moisture, woods are also observed to be favour- 
able to the action of miasma. Pringle, Cleghorn, and Jackson, 
have all made this observation. They may, and probably do. 
operate in part by confining the effluvia, and by concentrating 
their force ; whereas light and air otherwise would dissipate 
and dilute them. On this account, the practice of planting trees 
very close to a dwelling-house is injurious. But trees or woods 
may also have an injurious effect by the very moisture which 
they create, by preventing the access of the sun's rays to dis- 
sipate the vapour produced ; and its effects are manifest in the 
early decay of such buildings as are so closely surrounded by 
trees. Even brick and stone buildings show the effect of such 
16 



174 



LECTURE XIV. 



moisture constantly involving them ; the inhabitants, there- 
fore, must experience their ill effects. Yet it is remarked, 
that woods are, in some cases, useful too, to prevent the bad 
effects of miasma. The first cutting down and clearing the 
woods of North Carolina, begot diseases. The historian of 
that state observes, that the first colony were those who were 
sent out by Queen Anne, consisting chiefly of the persecuted 
protestant Palatinates — they did not remain in that part of the 
country, not getting the lands that had been promised them. 
The second colony of adventurers lived twelve months in 
that country before it was cleared, and lost only five men out 
of one hundred and seven — though badly sheltered and badly 
fed ; but the trees being cut down, and the surface of the earth 
exposed to the sun, the exhalations, says Dr. Williamson, soon 
gave rise to fevers. 

Woods are also useful, when they are situated between an 
encampment or a dwelling and marshy ground. Whole fami- 
lies, says Mr. Bartlet, have resided near the Pontine marshes 
in the vicinity of Rome, and by the intervention of shrubs and 
trees, have escaped for years the noxious effects of the mephitic 
vapours which those putrid waters engender. See Thompson's 
Annals. Observations by J. M. Bartlet. See Edinburgh Journal 
for July, 1820, p. 621. 

Dr. Williamson, in his late History of North Carolina, states 
a very striking instance of this effect, produced by a piece of 
wood. A gentleman in Craven county, with a family consist- 
ing of fifty or sixty persons, lived forty years without inter- 
mittents. But in 1785, he cut down a thick wood for pasture 
and fresh air — thirteen of his family the next year were at- 
tacked with intermittents. Col. Howell's family, too, in New 
Jersey, was attacked with fever, in consequence of cutting 
down a wood that separated them from a morass in the neigh- 
bourhood. Before that operation, they had been healthy ; but 
the consequence of this change was, that most of the family 
were attacked with fevers — three died — eight or ten recovered 
by means of blisters, and the free use of bark, wine, and 
snakeroot. Similar facts have frequently occurred in the 
West Indies. 

3d. The cold of the night air is favourable to the action of 
miasmata. All sudden changes of temperature or season give 



CAUSES OF FEVER. 175 

effect to it, as a cold night after a warm day. " A cold and 
wet autumn," says Raymond, " after a hot and dry summer, 
spreads and renders fevers more malignant." Raymond, In- 
termittents of Mettleburgh. See also Wilson, p. 85. Bade- 
nock, vol. iv. Obs. and Enq., ascribes the bilious remittents of 
warm latitudes to the cold night air, as one of the principal 
exciting causes. Bontius observes, that the w T orst fevers of 
Batavia are produced by night air. Lind also states, that 
the boat of the Med way man-of-war, while at Batavia, attend- 
ing the shore at night for the purpose of procuring provisions, 
was no less than three times successively manned, having lost 
her hands in that service. 

4th. Temperate seasons are also most favourable to the ac- 
tion of miasma, viz. spring and autumn. So also are temper- 
ate climates, neither very hot nor very cold. Intermittent s 
are accordingly seldom met with very near the Equator. Bon- 
tius, Lysons, and Clarke, concur in this remark. In very hot 
latitudes, if they do exist, they assume a more malignant cha- 
racter, blended with typhous symptoms ; and in this w r ay they 
become contagious, as stated by Cleghorn. See also Wilson, 
p. 91. 

5th. The mixture of sea water with the water of marshes, 
is said by Pringle to produce a more noxious exhalation than 
miasma alone. Pringle drew this conclusion from his experi- 
ments, showing that a small quantity of salt promotes putre- 
faction. This is sanctioned, too, by his experiments, for the 
purpose of showing that salt favours putrefaction ; but the di- 
lution more than counteracts this tendency. Accordingly, this 
is not confirmed by other writers. It is observed by Jackson 
in Jamaica, and on the coast of the Carolinas, where the sea 
and river waters are mixed, that those places are not more 
unhealthy than those where they are separated. It is also a 
fact, observed at Hoboken, in the vicinity of this city, that it 
has become very sickly since the sea water has been kept out 
by embankments. Before these embankments, no intermittents 
or remittents existed — now they are so frequent and formidable, 
that many persons have removed to town, to avoid the fevers 
of that place and its vicinity. Mr. Stevens informs me, that 
during the summer of 1812, the salt water was again admit- 
ted — the marshes as formerly were overflowed, and they en- 



176 LECTURE XIV. 

joyed an exemption from their usual visitants — intermitting and 
remitting fevers. 

9th. Contagion is another of the exciting causes of fever. 
It is sometimes, like miasma, a predisposing cause of fever, for 
a person may have contagion in his system, and yet escape 
disease, unless it be called into action by heat, cold, fatigue, 
or intemperance. For the most part, however, it is sufficient 
of itself, as an exciting cause, to produce disease. It is, in- 
deed, the source of a great number and variety of fevers and 
febrile diseases. The term contagion is derived from the 
verb contango, signifying to touch, or to come in contact. 
And accordingly it signifies, in its strict etymological sense, 
the communication of disease by contact. Its meaning, how- 
ever, has been extended beyond these bounds, which the ety- 
mology of the term appears to prescribe. A contagious disease 
in the modern use of the term, denotes a disease in which a 
specific material is generated in the system, and which excret- 
ed, will communicate such disease from one person to another. 
But notwithstanding the apparent precision of this language, 
there is, perhaps, no subject which has ever occupied the 
human mind, that has created more controversy, and more 
confusion, than that of contagion ; especially that of defining 
the limits and circumstance which characterize a contagious 
disease. Truly it may be said, that clouds and darkness rest 
upon it. Some have proposed to confine the term contagious 
to diseases which are communicated by a specific matter, 
which can be taken but once in the course of life, and which 
can be communicated by inoculation as well as by contact. 
And the example they usually give of such specific contagion 
is small-pox. This they consider the most perfect example of 
the diseases they denominate specifically contagious. While 
to fevers that are communicable from one to another, some of 
which may be communicated by inoculation, as the plague, and 
may be taken frequently by the same person, they refuse the 
term specific contagion.* 

* " A considerable diversity of opinion has prevailed respecting the cause of 
fever. Physicians seem now to be agreed in referring it to a general or specific 
contagion, the former giving rise to typhus in the various forms under which it 
appears, while the exanthemata or eruptive fevers proceed from the latter." 
Hamilton on Purgatives, p. 14, 16. 



CAUSES OF FEVER. 177 

But this distinction, I contend, is a bad one in many re- 
spects, even upon their own principles. For instance, syphilis 
is surely communicated by a specific poison or material — it 
may be conveyed by the lancet or the knife, as well as by 
sexual intercourse, and accordingly we see it thus occasion- 
ally communicated by dissection. Yet syphilis, although it is 
thus restrained in the manner of its communication, viz. by 
contact, you all well know that it is frequently contracted by 
the same person. Here, then, is at once an exception to the 
character of a specifically contagious disease, as above defined, 
inasmuch as the pox may be taken frequently, and the small- 
pox but once. Dysentery, too, has its specific material as well 
as small-pox, though it may not be communicated by inocula- 
tion. Yet dysentery as uniformly and regularly produces dys- 
entery, as small-pox produces small-pox, though the one can be 
taken but once, while the other is frequently contracted by the 
same individual. 

The plague, too, has its specific material ; it can be taken 
frequently, and it can even be communicated by inoculation,* as 
I shall show you to-morrow. Yet it is not, in the sense they 
consider small-pox, one of the specifically contagious diseases. 

Other physicians, again, have confounded all contagious dis- 
eases, making no distinctions whatever as to the several modes 
of communication. Lind even, in his valuable papers on con- 
tagion and infection, is guilty of this error. 

The late Dr. Richard Bayley of this city, in his account of 
the yellow fever which prevailed in New York in 1795, pro- 
posed what at first view appears to be a plausible distinction 
between contagious and infectious diseases. He made use of 
the term contagious diseases, to distinguish those which are 
communicated under any circumstances of atmosphere, whe- 
ther foul or pure, as small-pox, measles, &c. Infectious 
diseases he denominated such as are communicated by the 



* It is said that Desgenettes inoculated for the plague some of the French 
soldiers in Egypt, but could not communicate the disease. But read his own 
account. He tells you that he did it for the purpose of giving confidence to the 
soldiers ; that he did it under circumstances unfavourable to its communication ; 
made use of the matter at too early a period of the disease ; and adds, " that 
the contagious nature of the plague was demonstrated by a thousand examples 
— demonstree par milles exemples." 
16* 



178 LECTURE XIV. 

impurities of the atmosphere, or by the foul air surrounding the 
patient. That is, that the impurities of the air communicate 
the disease — not that the air contains any specific material 
derived from the diseased body, except such as arises from 
mere want of cleanliness, and from the foul air surrounding the 
patient. But an obvious objection to this arrangement is, that 
the same disease under which the patient is suffering is com- 
municated to the visiter. He takes yellow fever, or dysentery, 
or typhus fever, when the sick man has any of these diseases ; 
and he receives no other. 

For this reason, then, I make use of the terms infectious 
and contagious, as synonymous : — yet each of the disorders so 
denominated, whether contagious or infectious, has its own 
peculiar laws. Others, again, are frequently contracted, as the 
clap and syphilis; indeed, without these peculiarities, they 
would be the same disease — they would truly be unit, as they 
have been considered by Dr. Rush and some of his followers, 
who are without his talents or genius to give the same plausi- 
bility to error that it received from that able and eloquent 
teacher and writer. No one, therefore, can be a standard of 
comparison for the others, as each disease has something pe- 
culiar to itself. Hence, then, we see the error of those who 
make small-pox a standard — and who pronounce upon the con- 
tagiousness or non-contagiousness of fevers and other diseases, 
according as they do or do not resemble small-pox. In this 
way they have reasoned upon the contagiousness of yellow 
fever, denying it altogether because it did not square with the 
disease they made choice of as the standard — because, for- 
sooth, the yellow fever was not small-pox. They might as 
well say that scarlet fever is not a contagious disease, because 
it has not the pustules of small-pox ; or, they might say, that 
even small-pox is not contagious, because it has not the buboes 
of plague or syphilis. As an old lady, after listening to a 
learned disquisition on these distinctions, said, " At any rate 
they are catching diseases." In like manner, I call them all 
communicable diseases — communicable from one person to an- 
other. But, as some of these diseases are conveyed in one 
form, and others in a different, we should be careful to mark 
those circumstances in which they differ, as well as those they 
possess in common. Can this be accomplished ? 



CAUSES OF FEVER. 179 

Such an arrangement appears to me not only to be practi- 
cable, but at the same time calculated, in some degree, to bring 
the contagionists and non-contagionists together. Und^r these 
impressions, in the year 1808, in a letter addressed to Dr. 
Chisholm, I first suggested my reflections on this subject, and 
proposed to arrange all those diseases which are communica- 
ble from one to another into three great classes, according to 
the several laws which appear to govern their communica- 
tion. See American Medical and Philosophical Register, vol. 
ii. p. 17-22. 

Dr. Chisholm expressed his approbation of the first two 
classes, but objected to the third that the foul air which I 
made the medium of communicating the contagion, and of 
spreading the disease, only operated by predisposing the body 
to receive the contagion from the individual to whom he might 
be exposed, but that it could have no other operation — but this 
certainly is not all. Dr. Chisholm requested me to reconsider 
the subject. I have done so : the result of that consideration 
will be laid before you at our meeting to-morrow. 



180 



LECTURE XV. 



CONTAGION, AND ITS LAWS. 



As I stated to you in the last lecture — in July, 1808, I ad- 
dressed to Dr. Chisholm some observations on contagion, or 
infection.* The object of that communication was, if possible, 
to narrow the ground of controversy upon that important and 
much contested subject. This I endeavoured to do, first, by 
showing that the distinction which had been proposed by some 
late writers, between contagion and infection, was unnecessary 
and fallacious ; secondly, by dividing all diseases which are 
contagious, infectious, or communicable from one person to 
another, into different classes, according to the several laws 
which appear to govern their communication. These classes 
are three in number. 

The first embracing those diseases which are communicated 
exclusively by contact ; as the itch, syphilis, hydrophobia, &c. 
which are never conveyed through the medium of the atmo- 
sphere. 

The second including those diseases which are communica- 
ble both by contact, or the near approach to the sick, and by 
the atmosphere, as measles, small-pox, scarlet fever, &c. which 
are communicable in every season of the year, and in every 
climate ; in a pure as well as in an impure air, though more 
readily by means of the latter than the former, and with which 
persons are rarely infected more than once in their lives. 

Under the third class are enumerated those diseases which 
are only, in general, communicable or contagious through the 

* See Edinburgh Med. and Surg. Journal, vol. v. p. 247. American Medical 
and Philosophical Register, vol. ii. p. 14. 



CONTAGION, AND ITS LAWS. 181 

medium of an impure atmosphere ; the air being rendered thus 
impure by the decomposition of animal and vegetable sub- 
stances, as in low, marshy countries ; or by concentrated hu- 
man effluvia, as in camps, jails, hospitals, or on shipboard ; but 
the same diseases I alleged, in a pure air, in large and well 
ventilated apartments, when the dress of the patient is frequent- 
ly changed, all excrementitious discharges constantly removed, 
and attention paid to cleanliness in general, are not usually 
contagious, or, under such circumstances, are very rarely com- 
municated from one person to another. 

In this class I included the plague, dysentery, typhus fever, 
in its various forms of jail, ship, hospital, or lake fever, and 
the yellow fever. 

I also remarked, that these diseases, like many of the first 
class, may be repeatedly contracted ; but that they are com- 
municable, or otherwise, according to the condition of the air 
in which they occur, or into which they may be introduced : it 
was further observed, that the atmosphere thus impregnated by 
the peculiar virus emanating from the diseased body, becomes 
assimilated to the poison or ferment introduced, and thereby is 
rendered capable of reproducing in others the same specific 
disease, whether it be the plague, dysentery, typhus, or yellow 
fever. Such are the outlines of my first communication to 
Dr. Chisholm. 

In 1809, Dr. Chisholm did me the honour to reply* to the 
foregoing observations, expressing his entire approbation of the 
first two classes, but objecting to the third. After enumerating 
his several objections, he requests me to reconsider my third 
division, which appears to him to be the only objectionable 
one. This I have done, and now submit the result of a further 
examination of this subject, and a detail of the facts by which 
I have been led to my conclusion relating to the laws of com- 
munication which I have more particularly assigned to the 
febrile diseases enumerated in the third class. 

In my first communication, I acknowledge I stated my ob- 
servations without so full a detail of the facts themselves whence 
my conclusions were deduced, as perhaps ought to have been 
exhibited. Yet they have been approved and adopted by the 

* See American Medical and Philosophical Register, vol. ii. p. 121. 



182 LECTURE XV. 

physicians of Edinburgh and London, as you may see in the 
Edinburgh Journal, and the London Register and Review. To 
the European reader, unacquainted with the peculiarities of yel- 
low fever, more especially as it has appeared in the cities of the 
United States, my first statement may perhaps appear defective 
in that evidence which is so justly exacted upon subjects of 
this nature. This evidence I shall now endeavour to supply, 
and thereby to confirm the correctness of the classification 
which has been proposed. 

Waiving for the present all inquiry relative to the nature or 
properties of the contagious principles secreted by the diseased 
body, or the chemical qualities of the atmosphere deemed ne- 
cessary for its propagation, or the manner in which the con- 
tagion diffuses itself, I proceed to observe, that the history of 
each disease enumerated in the third class, viz. plague, dysen- 
tery, typhus, in all its forms, and yellow fever, furnishes evi- 
dence of the correctness of the remark, that they are governed 
by a law peculiar to themselves, that they are contagious or 
communicable in a foul atmosphere, but that they are never or 
very rarely so in a pure air, where the sick enjoy the benefits 
of cleanliness and ventilation. 

The same evidence, I trust, will demonstrate another truth, 
that these diseases are in no instances epidemic, as they have 
been improperly denominated by most practical writers, but 
that their sphere of operation is, with very few exceptions, 
confined within the limits to which the vitiated atmosphere ex- 
tends, in which they may be engendered, or into which they 
may be introduced : and that, in this respect, they differ from 
ordinary epidemics, " which appear in different and distant 
parts of the same place, and at the same time." 

That the plague when once generated, whatever may be the 
sources whence it derives its origin, is communicated by a pe- 
culiar virus secreted by the diseased body, will not, I trust, be 
questioned at this day. Independently of the facts contained 
in the writings of Thucydides, Lucretius, Mead, Dr. Patrick 
Russell, and others, showing the contagious nature of the 
plague, the communication of this disease by inoculation, as 
performed by Mathias Deggio,* Dr. Whyte,f and the Russian 

* See Med. Com. vol. viii. p. 349. 

t See Wilson's Expedition to Egypt, and M'Gregor's Sketches. 



CONTAGION, AND ITS LAWS. 183 

surgeon noticed by Sonnini,* have recently established the fact 
of its propagation by a specific secretion, beyond all possible 
controversy. 

It has been observed by Assalini, that Dr. Desgenettes, while 
in Syria, had in vain endeavoured to inoculate himself with 
the virus of the plague : and by the same writer it is incorrectly 
added, that Dr. Desgenettes made the experiment under the 
persuasion that the disease was not contagious : but from the 
account of the facts as stated by Dr. Desgenettes himself, it 
appears that the experiment was not made under that persua- 
sion. On the contrary, he expressly declares, that its conta- 
giousness was demonstrated by " a thousand examples," and 
observes, contrary to the opinion of many, that the same per- 
son was liable to a second attack of it, as was the case with 
the convalescents w r hom he employed to attend upon the sick. 
Furthermore it appears, from his own account, that he inocu- 
lated himself with the matter taken from a person who had 
the disease in its mildest form, what he denominates the first 
degree ; in which the fever was slight, and the patient easily 
and promptly cured. Dr. Desgenettes adds, that it was an im- 
perfect experiment, and that it does not disprove the commu- 
nication of the disease by contagion ; and that he made the 
experiment for the purpose of quieting the fears of the French 
troops, and of inspiring them with confidence. 

But that the plague, in common with the other diseases I 
have associated with it, is only communicable through the me- 
dium of an impure or vitiated atmosphere, is an opinion which, 
although it has never been attended to by physicians, will be 
found to be verified by almost every writer on this disease. 

1st. The plague of Athens, the first of which we have any 
authentic or satisfactory account, furnishes evidence of the 
truth. Whether that disease originated in the city of Athens, 
or was introduced into it from Ethiopia, the fact is established, 
that the circumstances under which it appeared in that city 
were peculiarly favourable to its diffusion. It appeared, ac- 
cording to Thucydides, in the beginning of the summer sea- 
son, and first of all at the Piraeus, the port and harbour of 
Athens, from whence it spread with increasing mortality into 

* See Travels into Greece and Turkey, p. 497. 



184 LECTURE XV. 

the upper part of the city. It appeared, too, at a time when 
Athens was so crowded with those who had fled thither from 
the adjacent country of Attica for safety from the invading ar- 
mies of the Peloponnesians and their allies, that many of them 
were forced to lodge themselves within the turrets of the walls, 
or wherever they could find a vacant corner. " The city," says 
the historian, " was not able to receive so large a conflux of 
people :" " afterwards the long walls, and a great part of the 
Piraeus, were portioned out to them for little dwellings ; at the 
same time, too, the Athenians were fitting out, at the Piraeus, a 
fleet of one hundred ships to infest Peloponnesus." Even the 
Pelasgic, a hitherto vacant spot of ground below the citadel, 
w r hich it was thought profaneness to occupy, and the settlement 
of which the Pythian oracle had specially prohibited, they were 
constrained, by urgent necessity, to turn into a dwelling-place. 
By this influx from the neighbourhood of Athens, its number of 
inhabitants, as stated by a late writer, was suddenly increased 
from fifty thousand to more than four hundred thousand per- 
sons.* In another place, Thucydides observes, " Those who 
had come in from the country had no houses, but dwelled all 
the summer season in booths, where there was scarcely room 
to breathe." He adds, " The pestilence destroyed with the ut- 
most disorder, so that they lay together in heaps, the dying 
upon the dead, and the dead upon the dying." Even in the 
public streets, some were tumbling one over another, or lay 
expiring round about every fountain, whither they had crept to 
assuage their immoderate thirst. The temples, too, in which 
they had erected tents for their reception, were full of the 
bodies of those who had expired there. Thucydides proceeds : 
" In a calamity so outrageously violent, things sacred and holy 
had quite lost their distinction ; all regulations observed before 
in matters of sepulture were quite confounded, since every one 
buried wherever he could find a place." He also observes : 
" It raged the most, and for the longest time, in Athens, but 
afterwards spread into the other towns, especially in the most 
populous, but never extended itself to Peloponnesus." We are 
told by the same historian, that " at the siege of Potidaea, 
which took place during the same season, the plague followed 

* Medical Repository, vol. i. p. 16. 



CON'TAGION, AiVD ITS LAWS. 185 

them even thither, and, making grievous havoc among the 
Athenians, destroyed the army ; and that even those soldiers 
that had been there before, and had from the beginning of the 
siege been in perfect health, caught the infection from the 
troops brought thither by Agnon. After a stay of forty days, 
having, in that time, lost one thousand and fifty out of four 
thousand men, he returned with his ships to Athens."* 

With these facts before us, the season of the year in w T hich 
the plague made its first appearance, the part of the city in 
which it commenced, the multitudes which crowded into it, 
and those too unaccustomed to the air of the town, having 
been habituated to active employment in the pure air of the 
country, the impure state of the atmosphere necessarily result- 
ing from this condition of things, combining the evils both of 
pestilence and war ; the disease itself being confined w r ithin the 
walls of the city, while, at the same time, it never extended 
itself to the neighbouring country, not even to the contiguous 
towns of Peloponnesus and Boeotia, we are led to the conclu- 
sion, at least to the strongest presumptive evidence, that an 
impure atmosphere is the vehicle or medium by which this 
disease is propagated. 

2d. The circumstances attendant upon the plague, as it has 
appeared at different periods in the city of Rome, are no less 
demonstrative of this truth. I will only notice the more re- 
markable visitation of this disease which took place in the year 
of Rome 290, and four hundred and sixty-one years before 
Christ. " This," says Livy, " was a season of great distress ; 
for during this year a pestilential disorder spread itself not only 
through the city, but over the country, affecting both men and 
cattle with equal malignity ; the violence of the disorder was 
increased by admitting into the city the cattle and the inhabi- 
tants of the country, who fled thither for shelter from the ene- 
my's ravages : such a confused collection of animals of every 
kind suffocated the citizens by the unusual stench, while the 
country people, crowded together in narrow apartments, suf- 
fered no less from the heat, the want of rest, and their attend- 

* Smith's Translation of Thucydides, vol. i. p. 153, 
17 



186 LECTURE XV. 

ance on each other ; besides even contact served to propagate 
the infection."* Baker's Livy. 

Dionysius of Halicarnassus mentionsf that the disease seized 
studs of mares, herds of oxen, and flocks of goats and sheep, 
doubtless denoting that this disease was remarkably fatal to 
those animals when collected in numerous bodies. Orosius, in 
his account of the same pestilence, observes, " Many of the 
patricians were victims, but it was most fatal to the poor." J 
Livy also has a similar observation, that many illustrious per- 
sons died, but that among those of inferior note the virulence 
of the disorder spread its ravages wide. 

3d. The history of the pestilence of modern times, the ac- 
counts of which are more minutely and satisfactorily detailed, 
no less proves that this disease, when once introduced, spreads 
its devastation by means of a vitiated atmosphere, more espe- 
cially where such vitiation proceeds from confined human 
effluvia. Erasmus, in 1515, in a letter to Franciscus (Wolsey's 
physician) ascribes plague, and the sweating sickness, partly to 
the incommodious form and bad exposure of the houses, to 
the filthiness of the street, and the sluttishness within doors. 
" The floors," he writes, "are commonly of clay, strewed with 
rushes, under which lies unmolested an ancient collection of 
beer, grease, fragments, bones, spittle, excrements of dogs and 
cats, and every thing that is nasty," &c.§ Diemerbroek also 
remarks, in his excellent treatise on the plague, that whenever 
that disease has been introduced out of its proper season it has 
not spread. It has also been observed by Dr. Russel, that in 
winter time, when infected persons have come to places about 
Aleppo, some of whom have died of the disease in families 
where they lodged, the distemper was not propagated. Dr. 
Hodges also stated that those who fled from London, in the 



* Grave tempus et forte annus pestilens erat urbi, agrisque, nee Iiominibus 
magis, quam pecori ; et auxere vim morbi tenore populationis, pecoribus agresti- 
busque, in urbem acceptis. Ea colluvio mixtorum omnis generis animantium, et 
odore insolito urbanos et agrestem confertum in areta tecta, sestu ac vigillis an- 
gebat, ministeriaque in vicem ac contagio ipsa vulgabant niorbos. Tit. Liv. lib. 
3. c. 6. 

t Lib. 10. t Lib. 2. 

^ Life of Erasmus by Laycey. Lond, 1805, 



CONTAGION, AND ITS LAWS. 187 

autumn of 1665, during the ravages of the plague, and returned 
in winter time to the houses and beds in which their friends 
died of the malady, escaped the infection. It therefore depends 
both upon temperature and the condition of atmosphere for its 
propagation. 

It is likewise an unquestionable fact, says Dr. Bateman, 
writer of the article Plague, (see Rees,) that this disease has 
always first appeared and established its head quarters in the 
filthiest parts of crowded, ill-constructed, and large cities, and 
has committed its most fatal ravages among the lowest of the 
people. Thus at Grand Cairo and Constantinople it appears 
almost annually. 

In London, Dr. Heberden observes that the plague of 1626 
and 1636, broke out at White-Chapel, a part of the town which 
abounds with the poor and with slaughter-houses. In the 
plague of London, in 1665, at which time nearly one hundred 
thousand persons perished, it is stated to have broken out first 
at St. Giles's. We are also told by Hodges, that while the bet- 
ter sort of people had various resources to avoid the dreadful 
consequences of this fatal distemper, it was entirely confined 
to the poor, insomuch that some gave it the name of the poor's 
plague. 

The rich, says Mr. Howard, are less liable to the plague 
than the poor, both because they are more careful to avoid in- 
fection and have larger and more airy apartments, and because 
they are more cleanly, and live on better food, with plenty of 
vegetables ; and this I suppose is the reason why protestants 
are less liable to this distemper than catholics during their time 
of fasting ; and likewise, why the generality of Europeans are 
less liable to it than Greeks, and particularly Jews. He adds, 
I have heard of instances of servants in European families, 
who, through imprudence and carelessness, have been attacked 
with the plague, while the rest of the family escaped it.* 

We are told by Diemerbroek, that it was a common prac- 
tice in Italy and France, when the plague appeared in any large 
town, to drive out the poor immediately : so fully were the ma- 
gistrates convinced that the disease was preserved and propa- 
gated by them. Upon the same principle, at the commence- 

* Account of Lazarettos, p. 52. 



188 LECTURE XV. 

ment of the plague at Marseilles, all beggars were ordered to 
quit the town.* " Indeed," says Dr. Blane, " it is a general re- 
mark in the history of all plagues, both in Asia and Europe, 
that they break out and prevail only among the lowest and 
poorest ranks of people, never becoming epidemic among the 
better sort."f When the plague was last in England, upon its 
first entrance into Poole, in Dorsetshire, the magistrates imme- 
diately suppressed it by removing the sick into pest houses 
without the town.J 

Lord Clarendon, in the history of his own life, relates that 
when he and other people of condition, who had fled from the 
plague, returned to London, they hardly missed one of their 
friends or acquaintances, the mortality having been confined 
almost entirely to the lowest orders of the people. " At that 
time, too, the streets of London," says Thornton, " were nar- 
row, crooked, and incommodious, the buildings chiefly of wood, 
dark, close, and ill contrived, and by the several stories pro- 
jecting beyond each other as they rose over the narrow streets, 
the circulation of the air was almost entirely obstructed. To 
these inconveniences," he adds, " may in some measure be at- 
tributed the destruction which had been repeatedly made in the 
city by the visitation of the plague ; for as the air was confined, 
so the noisome vapours and pestilential atoms were harboured 
and nourished. Though the destruction of London by the 
great fire in the succeeding year (1666) occasioned great tem- 
porary distress, yet, in the end, it proved of the utmost utility ; 
for, by the rebuilding of the city, and the enlargement of the 
streets, the free circulation of air was admitted, the offensive 
vapours expelled, and the city freed from all pestilential disor- 
ders."§ It is also stated by Dr. Hodges,|| that at the breaking 
out of this plague, the city was unusually full of people : he 
supposes that there must have been upwards of one hundred 
thousand persons more than usual in the city ; and according to 
Dr. Baynard, during the progress of this merciless pestilence, 
there was such a general calm and serenity of weather as if 



* Ferriar's Med. Hist, and Reflect, vol. i. p. 287. 

t Diseases of Seamen, 3d ed. p. 622. 

X Roberton's Med. Police, vol. ii. p. 149. 

§ Thornton's History of London, I! De Peste, 



CONTAGION, AND ITS LAWS. 189 

both wind and rain had been expelled the kingdom, and that 
for many weeks together not the least breath of wind could be 
discovered. 

It is also worthy of remark, that the city of Oxford, to which 
the parliament was removed during the prevalence of this dis- 
ease, remained uninfected; which exemption is ascribed, by 
Dr. Plott, to the draining and greater cleanliness of that city.* 

4th. The great plague with which Marseilles w 7 as visited in 
1720, and which destroyed upwards of sixty thousand of its 
inhabitants, presents us w T ith a detail of facts which leads to 
the same conclusion. Blackmore takes notice, that the impurity 
and filth connected with the galleys and slaves at Marseilles, 
filled the air with offensive smells, and in 1720 the plague broke 
out there in a part of the town thronged by the poorest people. 
This disease, it is well ascertained, was introduced from the 
Levant by a ship which arrived at Marseilles from the coast of 
Syria. It appeared first among the sailors of the suspected 
ship ; it was next taken by the porters engaged in opening and 
airing the merchandise in the Lazaretto ; it was then introduced 
into the city, and spread among the poor, and first of all in a 
street which was only occupied by the low r er class of people.-)- 

In the commencement of the disease, Bertrand remarks, 
none but children and poor persons were attacked by it.J In 
a short time it extended to the neighbouring streets ; it was 
also conveyed into the Hotel Dieu, by a person received as a 
patient from the street where the distemper first broke out ; two 
of the nurses and the matron of that institution first died of the 
disease, when the infection spread with great mortality, de- 
stroying the physicians,^ surgeons, apothecaries, confessors, and 
all the other officers and servants of the house, with the whole 
of the poor in the hospital, including above three hundred 
foundlings. || 

Soon after, all intercourse was prohibited between the town 
and neighbouring country ; the scarcity of provisions which 
ensued, independently of the crowded state of the city, greatly 

* History of Oxfordshire. 

t Bertrand's Relation Historique, p. 414. t Bertrand, p. 50, 

§ Speaking of the plague of Egypt in 1800 and 1801, Sir James M'G-regor 
tells us, that of thirteen physicians seven were attacked with the disease, and 
that of this number four died. H Bertrand, p. 92. 

17* 



190 LECTURE XV. 

added to the mortality of the disease : the number of the sick 
increasing, an hospital was opened for the reception of the in- 
fected, where the disease proved fatal to all the attendants. But 
the disease was not only propagated in those public institutions, 
where great numbers were crowded together, and in the con- 
fined dwellings of the poor ; other circumstances occurred 
which served greatly to diffuse the poison still more generally 
throughout the city. According to Bertrand, the streets were 
crowded with " the sick, the dying, and the dead," and the va- 
pours which arose from the putrid dead bodies, in every part 
of the city, served to infect the air and spread the contagion ; 
indeed, it soon extended to places that before this had been in- 
accessible to it ; monasteries, and houses shut up in the most 
exact manner, were no longer places of security; the whole 
city became more or less one infirmary.* 

The infection, too, was very much increased from another 
source not less dangerous. An opinion prevailed that the dogs 
received the contagion from contact with infected clothes, and 
thereby became the means of spreading it still more extensively; 
. the consequence was, an order to destroy them : in a few days 
the streets were strewed with their carcasses ; a prodigious 
quantity were thrown into the water ; these also were soon cast 
upon the shore, where, by the action of a hot sun, the air was 
filled with the most noxious vapours. Infected clothing and 
furniture were also continually thrown into the streets from the 
windows of the houses in which the disease prevailed ; and, if 
possible, still further to give wings to the poison, fires were in- 
judiciously had recourse to, for the purpose of destroying the 
infection. " At hours appointed," says Bertrand, " the whole 
city appeared on fire, and the air became loaded with a thick 
black smoke, better calculated to retain than to dissipate the 
contagious vapour. "f In fact, these fires, he adds, appeared to 
relume that of the contagion ; " they heated the air, already 
rendered suffocating by the heat of the season and climate ; the 
pestilential poison became more active, and the disease acquired 
new force."J 

5th. The plague of Aleppo, in 1760, 1761, and 1762, might 
also be cited upon this occasion, as well as many others, both 

* Bertrand, p. 145. f Ibid. p. 74. I Ibid. p. 75. 



CONTAGION, AND ITS LAWS. 191 

anterior and subsequent to that period, to show that the epi- 
demic influence of this disease is chiefly dependent upon the 
atmosphere into which it may be introduced. 

6th. I cannot however pass over without comment, the 
plague which the British and French troops suffered during the 
celebrated expedition to Egypt in 1800 and 1801, inasmuch as 
it will show that this disease, even in its native climate, is go- 
verned by the same laws of communication which have been 
observed when it has been introduced into other countries. 

We are accordingly told, by the learned Dr. Wittman,* 
" that the disease is more prevalent at Rosetta than in any 
other town, or part of Egypt ;" he adds, " the streets of Ro- 
setta are extremely narrow and very dirty. The crowded 
manner in which the inhabitants live together would appear 
sufficient, in a stagnant state of the atmosphere, in most of their 
towns, to generate pestilential or malignant diseases. The 
. very few comforts and conveniences w T hich fall to the lot of the 
poorer class of the natives of Egypt, by far the most numerous, 
would lead one naturally to expect great mortality when the 
plague prevails among them. Dreadful examples are seen an- 
nually to happen." In another part of the same work, he is 
still more explicit on this point, showing that the plague " does 
not always possess the same activity and force ;" and the ne- 
cessity, as he expresses it, of some " powerful agent to put the 
contagion into action, and give it its full force." He then asks, 
" May this agent reside in the atmosphere ? Does this peculiar 
constitution of the air consist in a superabundance, or diminu- 
tion, of the ordinary proportion of oxygen in the atmosphere ? 
or in the combination of some peculiar gas or gases diffused 
in it?" He suggests that a series of eudiometrical and other 
observations, continued for several years, might throw some 
light on this subject. " Time alone," he adds, " may unfold 
this mystery."! But when we take into view the facts he has 
already stated relative to Rosetta, and are told by the same 
author that in Egypt the plague prevails when the Nile is low, 
and of course the air loaded with impurities thence arising ; that 
at Constantinople, the cold weather, in winter, puts a period to 
its progress ; and the still more general observation, that the ex- 

* Travels in Egypt, p. 525. t Ibid, p. 533. 



192 LECTURE XV. 

tremes both of heat and cold are unfavourable to the propaga- 
tion of plague ; — these facts, in connexion with those already 
stated of this disease, as it has appeared at different times and 
in different parts of the world, are certainly calculated to dis- 
sipate much of the mystery in which this subject has been en- 
veloped. The remarks of Dr. M'Gregor, (now Sir James 
M'Gregor, principal of the medical staff,) that the plague varies 
its type according to the state of the air, and other circum- 
stances, and that by ventilation, fumigation, and attention to 
cleanliness, the progress of the disease was arrested,* also 
serve to confirm the correctness of the view which has been 
taken of this subject. Even the writings of Assalini, who dis- 
believes the communication of this disease by contagion, fur- 
nish additional support to the principle here contended for ; for 
he admits that when persons are shut up and crowded together 
in infected places, the disease is readily contracted-! In an- 
other place he observes, " that if a person be exposed to breathe 
the infected air in the chamber of a patient, or should he stay 
too long in the same atmosphere, he will run a great risk of 
contracting the prevailing malady."J He moreover proceeds ; 
in order to prevent all suspicion, and avoid all danger of car- 
rying the disease where it has not been before, that they should 
take nothing with them but the necessaries of life ; they should 
avoid, as much as possible, halting in villages ; and each time 
when they happen to encamp, they should expose their baggage 
and clothes to the air, which would not fail of dispersing every 
particle of contagion. As a further evidence, too, of the con- 
nexion between the prevalence of the disease and the state of 
the air, he remarks, that during the epidemic, " the inhabitants 
residing near the sea were more exposed than those who were 
at some distance, and that there were several villages situated 
on the heights which had not even a single sick person." In 
many other parts of his work, he shows that his mind was not 
totally divested of belief in the communication of the plague 
by contagion ; and when danger approaches, like some modern 
professors of religion, he proves himself to be the practical 
infidel, by distrusting even his own doctrines ; for he takes great 



* Med. Sketches, p. 111. t Observations sur la Peste. 

1 Observations, &c. 



CONTAGION, AND ITS LAWS. 193 

pains to inform us of the various means he made use of to pro- 
tect himself against the disease, and which are both as efficient 
and judicious as the most sturdy contagionist could possibly 
have employed. Imlac, in Rasselas, speaking of the appear- 
ance of departed spirits, says, " Some who deny it with their 
tongues, confess it by their fears." So with Assalini, and, in- 
deed, the same may be said of many others who affect to dis- 
believe the doctrine of contagion, but who are among the first 
to fly from the disease whenever it made its appearance in our 
cities. And they w^ere the first to write on this subject ; and 
wrote the most. Indeed, some of the very books that were 
published by them w r ere written, not on the battle ground, but 
actually on the Catskill mountains. Is it possible, then, that 
you can attach value to such flying observations as these must 
necessarily be ? 

7th. In addition to the details cited from Thucydides, Livy, 
and from the writers of modern times, I might here introduce 
similar facts recorded of the plague of Florence, which ap- 
peared in that city in 1348.* 

But to conclude upon this part of the subject, and in the lan- 
guage of Dr. Chisholm himself, " Every physician who has 
delivered his opinion of the origin of the plague maintains, that 
a peculiar state of the air is absolutely necessary to establish 
the powers of contagion, and give circulation to the imported 
infection."! 

Another disease which I have placed in the same class with 
the plague, and have considered as governed by the same law 7 s 
of communication, is dysentery. By this disease I mean not 
that local affection of the bowels which is frequently symptom- 
atic of diarrhoea, and unaccompanied wqth fever, but that form 
of it which has been described by Sir John Pringle, Sir Gil- 
bert Blane, and other practical writers, under the title of epi- 
demic dysentery, or the dysentery of camps. 

This disease, like the plague, appears also to derive much of 
its infectious character from the condition of the atmosphere 
in which it takes place. In pure air, where cleanliness and 
ventilation are attended to, it rarely extends beyond the indi- 

* See Introduction to Boccacio's Decameron. 

t Essay on the Malignant Pestilential Fever, vol. i. p. 286. 



194 LECTURE XV. 

vidual in whom it first originates ; but in a vitiated atmosphere, 
loaded with moisture, marsh effluvia, or the perspirable matter, 
and other excretions of the human body, especially where many 
persons are crowded together and in small apartments, dysen- 
tery communicates itself to the greater part of those who may 
be exposed to its influence. Zimmerman remarks, that " in 
general it appears to him that dysentery became contagious 
purely through nastiness and the crowding many people to- 
gether in a small space, but was by no means so of itself."* 

And as a further evidence that the disease was derived not 
from the noxious qualities of the atmosphere alone, but from 
contagion communicated through that vitiated medium, he also 
observes of the dysentery which occurred at Dettingen, in 1743, 
that such of the officers, among whom it was not so general 
as among the soldiers, as had lain wet at Dettingen, were first 
attacked by it ; the rest received it by contagion : but a regi- 
ment that had not lain in the damp, nor been exposed to the 
rain, remained perfectly free from it, at a small distance from 
the camp ; though, excepting that they were not subject to the 
contagious effluvia of the rest, " they breathed the same air, 
ate the same provisions, and drank the same water."f And in 
the hospital in the village of Feckenheim, about a league from 
the camp, the dysentery being introduced, " the air became in- 
fected to such a degree that not only the rest of the patients, 
but even the apothecary, nurses, and the other servants, with 
most of the inhabitants of the village, were infected."J 

Dr. Donald Munro, who, as an army physician, had frequent 
opportunities of observing the character and progress of dysen- 
tery, ascribes the greater violence of this disease to obstructed 
perspiration, moist and putrid vapours, the putrid steams of 
dead horses, of the privies, excrements not covered with earth, 
or to the unwholesome, moist, putrescent vapours of marshy or 
wet grounds, or pools of stagnated water acted upon by the 
heat of summer, and of other corrupted animal or vegetable 
substances, all which served to increase the infection. Hence 
he observes, that in camps the more hot and rainy the season, 
the more wet and marshy the ground, and the more the air is 



* Zimmerman on Dysentery, p. 20. t Ibid. p. 26. 

i Ibid. 139. 



CONTAGION, AND ITS LAWS. 195 

replete with putrid vapours, the more frequent and the more 
fatal is the dysentery.* 

The remarks of Sir John Pringle are also in point on this 
subject. " Some dysenteries," he observes, " appear upon first 
taking the field, but the cases are never so bad nor nearly so 
frequent, as towards the end of summer ; they then become 
epidemic and contagious. They have always been numerous 
and w r orst after hot and close summers, especially in fixed 
camps, or when the men lay w r et after a march in warm wea- 
ther."! " In general the contagion does not suddenly spread ; 
for whole towns and camps are never seized at once from the 
impurities of the atmosphere ; but the infection is carried from 
one to another by the effluvia, or clothes and bedding, &c. as 
in the plague." " In camps the contagion passes from one who 
is ill to his companions in the same tent, and from thence, per- 
haps, to the next." " The foul straw," he adds, " becomes in- 
fectious ; but the greatest sources of infection are the privies, 
after they have received the dysenteric excrements of those 
who first sicken. The hospitals likewise spread it, since those 
who w r ere admitted with the flux not only gave it to the rest of 
the patients, but to the nurses and other attendants of the sick."J 
And to show that this disease is not dependent on a general 
constitution of the atmosphere, but upon that which is impure, 
and to which the dysenteric taint has been communicated, he 
observes of the epidemic which raged at Nimeguen, in 1736, 
" that none of the neighbouring towns suffered, unless by their 
communication with the place infected."§ Similar facts, illus- 
trative of the rapid extension of this disease, when introduced 
into ships of war, are recorded by Dr. Blane, in his valuable 
work on the Diseases of Seamen. 

That the contagiousness of typhus fever is also, in a great 
degree, ascribable to a similar condition of atmosphere as its 
pabulum, is demonstrated by facts recorded in almost every 
book of practice, more especially in those relating to the dis- 
eases of the army and navy, which have ever been found to 
be nurseries of this disease. The observations made upon this 
subject by the Linds, Pringle, Blane, Percival, Smyth, Trotter, 



* Diseases of the Army, vol. i. p. 314—316. t Ibid. p. 218, 7th ed. 

X Ibid. p. 254. § Ibid. p. 252. 



196 LECTURE XV. 

Haygarth, Ferriar, Currie, and others, relating to the spread of 
this disease, when introduced into hospitals and ships of war ; 
its prevalence and diffusion among the poor of London, Edin- 
burgh, Liverpool, and the manufacturing towns of Great Bri- 
tain; the beneficial effects which have been derived from the 
establishment of fever wards, and houses of recovery ; the ad- 
vantages which have been experienced from the fumigating or 
oxygenating processes introduced by Dr. Johnstone of Wor- 
cester, Guyton De Morveau, and Carmichael Smyth, in arrest- 
ing the progress of the typhus fever — all irresistibly lead to the 
conclusion, that the impurities of the air constitute the fuel of 
this disease ; and, to use the expressive language of Dr. Ferriar 
of Manchester, in a late communication which I have received 
from that learned physician, that " dilution with atmospheric 
air is now ascertained to be the most effectual mean of destroy- 
ing contagion, and of controlling the ravages of this disease."* 
Were it necessary, I might adduce a volume of additional 
testimony on this subject. I cannot, however, omit the follow- 
ing pertinent remark of Dr. Haygarth, who, like another How- 
ard, has devoted his life to the investigation of this interesting 
subject ; and to whom Great Britain is indebted for the first 
establishment of institutions specially devoted to the important 
purpose of arresting the progress of contagious diseases. In 
his remarks on the nature of the contagion which produces 
putrid fevers, he observes : " I soon discovered that their infec- 
tious atmosphere was limited to much narrower extent than 
even the small-pox. So manifestly I observed this to be the 
case, that in a clean, well-aired room, of a moderate size, the 
contagious poison is so much diluted with fresh air, that it very 
rarely produces the distemper, even in nurses exposed to all the 
putrid miasms of the breath, perspiration, faeces, &c. ; whereas, 
in the close, dirty, and small rooms of the poor, the whole fa- 
mily generally caught the fever. Hence we may conclude, 
that in well-aired and clean apartments, the air is seldom so 
fully impregnated with the poison as to acquire an infectious 
quality."f 



* See American Med. and Phil. Register, vol ii. 

f Proceedings of the Board of Health in Manchester.— Letter from Dr. Hay= 
garth to Dr. Percival, p. 8. 



CONTAGION, AND ITS LAWS. 197 

The observations of the late Dr. Willan are also in point on 
this subject. " Formerly," says that accurate observer, " the 
typhus, with petechia?, &c. often occurred in our prisons, and 
proved fatal to those who were under confinement in close 
cells, or who lodged in crowded apartments. Mr. Box, surgeon 
of Newgate, informs me that the fever has been rendered less 
frequent there, and less virulent, by removing the persons first 
affected into airy rooms, or wards, and by a general attention 
to ventilation, cleanliness, &c. ; so that, at present, petechia? do 
not appear in more than one case in thirty."* And of three 
hundred and seventy-nine patients committed into the London 
House of Recovery, says Dr. T. Bateman, nine only, or about 
one in forty-two, were affected with petechiae.f 

* Willan on Cutaneous Diseases, p. 469. t Ibid. 



18 



198 



LECTURE XVI. 



CONTAGION, AND ITS LAWS. 



The facts which have been ascertained relative to the 
communication of yellow fever, furnish no less conclusive 
evidence that this disease, like those already noticed, is, or is 
not, generally contagious, depending on the qualities of the air 
to which it may be communicated. The history of every 
visitation of the disease in the United States, establishes this 
truth. It has not only regularly made its first appearance in 
our sea-port towns, and in those places where the air is most 
impure; at that period of the year, and in those seasons when 
such impurities acquire their greatest virulence; in those houses 
which are most crowded with inhabitants, and were there is 
the least attention paid to cleanliness ; but, wherever the same 
disease has been thence conveyed to other parts of the same 
city, or town, or into the country, it either was propagated or 
extinguished, according to the local circumstances of the 
place to which it was so conveyed. 

1st. Dr. Lining, in his description of the yellow fever which 
was introduced into the city of Charleston in 1732, 1739, 1745, 
and in 1748, observes, that, although the infection was spread 
with great celerity through the town, yet, if any from the 
country received it in town, and sickened on their return 
home, the infection spread no further, not even so much as to 
one in the same house. He remarks, that the disease was 
generally more fatal to those who lay in small chambers not 
conveniently situated for the admission of fresh air.* 

* Edin. Phys. and Lit. Essay, vol. ii. p. 408, 427. 



CONTAGION, AND ITS LAWS. 199 

2d. The yellow fever with which the city of New York 
was visited in 1791, and which was introduced by a vessel 
from the West Indies, and rendered memorable by the death 
of one of our most respected citizens, General Malcolm, who 
was the first victim to the epidemic of that season, is thus re- 
corded by Dr. Jonas Addoms, in his excellent dissertation on 
that disease : 

" About the middle of August, 1791, a contagious fever ap- 
peared in the city of New York, which first discovered itself 
near Peck-slip, a part of the city thickly inhabited, its houses 
generally small, and badly ventilated ; many of the inhabitants 
were in indigent circumstances, which is a frequent cause of the 
want of cleanliness. Here it raged a considerable time ; it then 
began to spread, as some attendants on the sick became infected 
who lived in other neighbourhoods. By this means it was car- 
ried to other families, and most generally could be traced to this 
source. It likewise proved more particularly fatal near the 
place where it first appeared, than in any other part. Thus 
at length it spread through the city, until about the middle of 
October, w T hen the weather growing a little cooler, the disease 
greatly abated, and in a short time totally disappeared."* 

Dr. Addoms, the author of that dissertation, since that time 
resided many years in St. Croix, and being associated with a 
celebrated physician of that island, the late Dr. Gordon, had 
ample opportunities of seeing the yellow fever in all its forms. 
During his last visit to this city, not long before his death, he 
informed me that the disease which he had seen in New York 
in 1791, w'as precisely the same which he afterwards saw in St. 
Croix, and which frequently prevailed during his residence 
there, more especially among Europeans newly arrived within 
the tropics. He also remarked, at the same time, that this 
disease always acquired new virulence, and was rendered 
highly contagious, when introduced among soldiers crowded 
in barracks, or on shipboard. 

3d. In the yellow fever of 1793, which was introduced into 
the city of Philadelphia from the West Indies, it is conceded, 
on all sides, that the disease made its first appearance in 
Water street, and that all the cases of this fever were, for two 

* Inaugural Dissertation on Yellow Fever, p. 7. 



200 LECTURE XVT. 

or three weeks, evidently traced to that particular spot. It is 
also a fact well ascertained, that in the vicinity of the place 
where the infection was first received, the air was, at the same 
time, in a very offensive condition, from a quantity of damaged 
coffee which was exposed upon the dock, and under circum- 
stances favourable to its putrefaction and exhalation. From 
that place the disease gradually infected a considerable part 
of the city, the Northern Liberties and district of Southwark, 
and did not subside until terminated by frost, after having been 
fatal to nearly five thousand persons. 

It is also to be remarked, that its ravages were chiefly 
confined to the poor, and to those parts of the city where the 
houses were small, and the least attention given to cleanliness 
and ventilation. In the language of Mr. Carey, " it was 
dreadfully destructive among the poor. It is very probable 
that at least seven-eighths of the number of the dead were of 
that class ; the inhabitants of dirty houses have severely ex- 
piated their neglect of cleanliness and decency by the number 
of them that have fallen sacrifices. Whole families, in such 
houses, have sunk into one silent, undistinguishing grave. The 
mortality in confined streets, small alleys, and close houses, 
debarred the free circulation of air, has exceeded in a great 
proportion, that in the large streets, and well-aired houses. In 
some of the alleys a third or fourth of the whole of the inhab- 
itants are no more. The streets in the suburbs that had the 
benefit of the country air have suffered little. It is to be par- 
ticularly observed that, in general, the more remote the streets 
were from Water street, the less of the calamity they expe- 
rienced."* 

" Though the disease," says Dr. William Currie, " was 
highly contagious, the influence of the contagion was circum- 
scribed to a narrow sphere."! 

As a further evidence that it did not depend on a general 
condition of atmosphere, the same author remarks, " that 
while this formidable disease was making such ravages in the 
city, the country, for some miles around, was never more 
healthy. "J In another work Dr. Currie has very explicitly 

* Carey's Account, 4th edit. p. 61, 62. 

t Treatise on the Synochus Icterodes, p. 8. 

X Ibid. p. 11. 



CONTAGION, AND ITS LAWS. 201 

admitted the qualified contagiousness of yellow fever, observ- 
ing, " that it is only contagious in situations where the air is 
confined, and the exhalations of the sick are permitted to 
accumulate, through neglect of frequently changing the bed 
and body linen of the patient."* 

4th. Similar facts are recorded of the visitation which New 
York experienced of the same disease in 1795. Upon another 
occasion I shall make public the evidence which is in my 
possession, indisputably proving the importation of the yellow 
fever of that season from Port-au-Prince. In that year the 
disease appeared upon the east side of the city, first affecting 
some seamen who had received the infection from a brig 
directly from Port-au-Prince ; from thence it spread in the 
vicinity from Dover street to Peck-slip ; but throughout that 
season it was confined, in a great degree, to that part of the 
town where the local condition of the atmosphere w r as peculiar- 
ly favourable to its diffusion ; for not only an unusual quantity 
of filth was accumulated in Peck-slip, but at that very time a 
great number of emigrant poor had arrived from England, 
Ireland, and Scotland, so that the numerous lodging houses, 
especially in that neighbourhood, w r ere unusually crowded; 
add to this, that the weather was uncommonly moist, and 
thereby particularly calculated to spread the infection. Accord- 
ing to the statement made by Dr. Bayley, it was especially fatal 
to the emigrants of that very summer ; for " out of nearly 
eight hundred persons who died," he observes, " not more 
than one hundred and fifty were citizens of New York."f 

In another part of the same statement he remarks : " So 
limited was the operation of the contagion, that the number of 
those taken sick in low situations, compared with those re- 
siding in more elevated parts of the city, may be computed as 
twenty to one."J 

5th. In 1798 New York was again visited with this scourge 
of our sea-port towns : during the months of August, Septem- 
ber, and October, about two thousand persons fell victims to 
this disease, at the end of which time a keen frost put an 

* See Observ. on the Yellow Fever, in the Philad. Med. and Phys. Journal, 
vol. ii. part 1. 

t See Bayley on the Epidemic of 1796, p. 90. 

t Ibid. p. 80.— See also Letters to Dr, Buel by E. H. Smith. 

18* 



202 LECTURE XVI. 

almost instantaneous termination to its progress. The disease 
of that season first appeared at the ship-yards, in the neighbour- 
hood of New-slip, and, as in former years, was introduced 
from the West Indies.* After cutting off several persons in 
the neighbourhood in which it commenced, the same vessel 
was removed to the CofYee-House slip, also on the east side of 
the city; from thence the disease was communicated by those 
who worked on board to a thickly-settled part of the city, 
where the houses are small, the streets narrow, and chiefly 
occupied by the poor ; viz. Cliff street, John street, Ann street, 
Fair street, Eden's alley, and Rider street ; at the same time, 
however, it still continued to extend its ravages in the vicinity 
of the place to which the poison had been first communicated; 
and to some other thickly-settled parts of the town, to which 
it was subsequently conveyed. In a short time afterwards it 
was introduced into Pearl street, and in that part of it be- 
tween Burling and Peck slips, where it spread very extensive- 
ly. In that season a number of circumstances occurred to 
diffuse the contagion in that part of the city ; a great quantity 
of rain had fallen, so as to overflow the cellars in Pearl street, 
which were, at the same time, stored with salted provisions ; 
these were soon afterwards spoiled, and loaded the atmosphere 
with a highly offensive vapour; the disease raging at that time 
in that neighbourhood, acquired new virulence, and, for the 
most part, followed the course of the vitiated atmosphere ; 
" beyond the limits of which," says Mr. Webster, " the disease 
exhibited little infection :" indeed the extension of this disease, 
as has already been frequently observed, was so circumscribed 
within the limits of this impure air, that it became very gene- 
rally believed that, in that season, whatever may have been 
the case in former years, the disease exclusively arose from 
those domestic sources, more especially from the putrid 
provisions. But that the yellow fever of that season did not 
derive its origin from the spoiled beef is evident, not only from 
the fact that the disease had already previously appeared in 
other parts of the town, and even in that very neighbourhood, 
before those heavy rains had fallen, and their pernicious effects 

* See Statement of Facts on this subject by the Rev. Dr. M' Knight, in the 
Amer. Med. and Phil. Reg. vol. iii. 



CONTAGION, AND ITS LAWS. 203 

were perceived ; but also that those tainted provisions, un- 
accompanied with the specific poison of the disease, did not 
of themselves communicate infection to those who were con- 
stantly exposed to their effluvia. 

Mr. Edmund Prior, the inspector-general of beef at that 
time, informed me, that of forty persons whom he had employ- 
ed in examining the beef, and in removing and emptying such 
barrels as were found in a putrid state, not one was taken ill 
of the yellow fever. But Dr. Chisholm and Dr. Stewart 
have abundantly shown, that decomposed animal or vegetable 
matters will not, of themselves, produce the pestilence ; and 
that this disease is generated in the human system, and com- 
municated from one person to another, by a peculiar secre- 
tion from the morbid body. My object is to show, that when 
such virus is introduced into a certain state of atmosphere, the 
disease is readily multiplied and communicated, but that be- 
yond that atmosphere it is rarely infectious. 

Although the diseases which have been noticed are rarely 
communicable in pure air, and are not generally contagious in 
the country, it is not less true, that in some few instances it 
appears either that the virus, as secreted from the diseased 
body, is alone in sufficient quantity, or possesses a sufficient 
degree of virulence, to reproduce such diseases; or, that by 
means of the impurities collected about the diseased individual, 
occasioned by inattention to cleanliness and change of clothing, 
the retention of his excretions, or the confined air of his apart- 
ment, the virus itself becomes multiplied, and thereby the 
means of communicating the disease from one to another are 
in some degree increased: for it is a fact not to be questioned, 
that instances of yellow fever, as well as of the plague, 
dysentery, and typhus fever, have been occasionally infectious, 
even in the more pure air of the country, though it must be 
acknowledged that such cases are of rare occurrence. 

It is observed by Dr. Rush, whose records of the several 
visitations of the yellow fever in the city of Philadelphia will 
be lasting monuments of the facts which they contain, as well 
as the impressive and eloquent manner in which they are 
related, " that out of upwards of one thousand persons who 
have carried this disease into the country from our cities, 
there are not more than three or four instances to be met with 



204 LECTURE XVI. 

of its having been propagated by contagion."* Such instances, 
however, have occurred in New Hampshire, as related by Dr. 
Spalding ;f in Connecticut, as stated by Dr. William Moore, of 
this city;J on Staten Island, in 1798, as recorded by Dr. R. C. 
Moore,§ now the venerable bishop of Virginia; at Huntington, 
on Long Island, in 1795 and 1798 ;|| and at Germantown, in 
the vicinity of Philadelphia, as related by Dr. Wistar.H But 
these very exceptions, if they can with propriety be denomi- 
nated exceptions, manifestly prove the specific character of 
those diseases, and that they are propagated by a specific 
secretion peculiar to each disease, whether it be plague, dysen- 
tery, or yellow fever. Indeed, to use the emphatic expression 
of the Edinburgh Reviewers on this subject, " In the present 
state of medical knowledge, it would not be at all more absurd 
to deny the existence of fever altogether, than to maintain that 
it is not propagated by contagion."** But, in the language 
which Dr. Mead has applied to the plague, we may say of all 
the diseases of this class, " that a corrupted state of the air is, 
without doubt, necessary to give these contagious atoms their 
full force."ft 

If it were necessary, I might go on to cite every return of 
the yellow fever with which the United States have been visit- 
ed, to show that the progress of the pestilential poison has ever 
been commensurate with the impurities of the atmosphere, and 
that, when sufficiently diluted with pure air, it ceases to propa- 
gate itself. 

It is probably owing to this impure condition of the atmo- 
sphere that the various fevers, and the greater mortality of 
diseases in general, are to be ascribed, which physicians have 
frequently observed to precede the appearance of pestilential 
disorders, and to announce their approach, and which have 
led many to conclude that the pestilence itself was thus engen- 
dered by local circumstances, and not imported. 



* Observations on the Origin of the Yellow Fever of 1799, p. 12. 
t Med. Repos. vol. iii. p. 8. 

X Addoms's Disser. p. 7. Amer. Med. and Phil. Reg. vol. ii. p. 177. 
§ Ibid. vol. ii. p. 22. II Ibid. vol. iii. p. 191. 

f Additional Facts and Observations by the College of Physicians of Philadel- 
phia, p. 30. 

** Edinburgh Review, vol. i. 246. ft Mead's Medical Works. 



CONTAGION, AND ITS LAWS. 205 

Facts of this nature have served to mislead the editors of the 
Medical Repository, and many other late writers, who thus 
confound the exciting and predisposing causes of disease; who 
do not discriminate between the inflammable materials, and 
the spark which lights the flame; but have identified the 
domestic circumstances which have served to diffuse the poison 
of yellow fever, with the peculiar virus itself, by which that 
disease has been introduced into the various cities of the 
United States. 

The same local circumstances, I believe, will go far in 
accounting for the " pestilential state of the air," the " secret 
constitution of atmosphere," so often recorded by writers on 
epidemics; at the same time that they teach us, that the 
diseases now under consideration are only epidemic in as far 
as the vitiated state of the air is itself epidemic. 

I however wish it to be understood, that I do not exclude 
the influence of bodily predisposition, the passions of the mind, 
and many other circumstances, in aiding the propagation of 
pestilential diseases. 

Having, as I trust, shown, by the facts that have been ad- 
duced, that the plague, dysentery, typhus and yellow fever, 
constituting the third class of contagious diseases, require an 
impure state of the air to diffuse and multiply them, the ques- 
tion next presents itself, in what manner does such impure air 
operate in spreading those diseases ? Upon this part of the 
subject I have the misfortune to differ from Dr. Chisholm, no 
less than I do as to the necessity of such an atmosphere to 
propagate the peculiar poison of each of those diseases. Dr. 
Chisholm observes, that if the proposition had been advanced, 
" that those diseases, particularly the pestilential yellow fever, 
are rendered more violent in the action under the circum- 
stances stated of an impure atmosphere, that no possible objec- 
tion could be made to it, inasmuch as it is supported and 
proved by all experience ;" and he proceeds to express the 
opinion that such an atmosphere may have an effect " by 
rendering the system of the healthy person, who receives the 
poison from the sick, more susceptible at the moment of its 
introduction, of its peculiar action ;" but that this multiplying 
power does not proceed from any action of the air upon the 
peculiar virus of those diseases ; that " it does not proceed 



206 



LECTURE XVI. 



from the impure atmosphere becoming assimilated to the poison 
introduced." 

That air, deprived of its due proportion of oxygen, and load- 
ed with mephitic materials, especially the confined excretions 
of the human body, will vitiate the mass of circulating fluids, 
and impair the functions of the nervous system, cannot be 
denied ; that the febrile diseases with which the system may 
be affected while in this state, will acquire an extraordinary 
degree of malignancy, will also be readily conceded ; but that 
such condition, either of the atmosphere or of the human 
system, increases its susceptibility to be acted upon by the 
virus of those contagious diseases, composing the third class, 
does not correspond either with the facts which have fallen 
under my own observation, or with those I have been enabled 
to obtain from the writings and observations of others. 

The well known facts relative to the communication of 
" jail fever" to the judges presiding at the Black Assizes, in 
1577;* and a similar infection being communicated to the 
judges on the bench, and other persons present, at the sessions 
held at the Old Baily, in 1750, while the prisoners themselves 
remained in health, insensible to infection, furnish incontestible 
evidence of the effects of habit in diminishing the insensibility 
to the poison of fever. And with regard to the yellow fever, it 
assuredly has not been the case in the United States, that those 
who are most accustomed to the impure air of the place in 
which the disease prevailed, were more susceptible of the 
disorder than those who had recently arrived from the pure 
air of the country, or from the more elevated parts of the 
town. On the contrary, those who were least accustomed to 
the impure air of the city, or of the infected spot, were uniform- 
ly observed to be most susceptible of the contagion. Those, 
too, who enjoyed the most vigorous health, and the most ro- 
bust constitutions, the reverse of that condition of body which 
would be the effect of residence in impure air, were more 
readily infected upon coming into the atmosphere impregnated 
with the contagion, than those who had remained constantly 
exposed to its influence. Whatever differences of opinion 
have existed among the physicians of the United States as to 

* Bacon's Works, vol. ii. Stow's Chronicle. 



CONTAGION, AND ITS LAWS. 207 

the origin of the disease, they all perfectly agreed relative to 
the facts which I have just stated. Indeed, Dr. Chisholm him- 
self inadvertently admits the same to be true ; for he observes, 
that, in the West Indies, sailors, soldiers, and young men, 
especially those who had recently arrived from Europe, and 
are least accustomed to the climate, were more obnoxious to 
it than others.* 

Dr. Gordon, and indeed all the most distinguished practical 
writers on this subject, concur in the same observation. " New 
comers," says Dr. Gordon, in the appendix to Dr. Chisholm's 
late valuable letter to Dr. Haygarth, " were infected with the 
pestilential fever, while the old seasoned soldiers had only the 
tropical remittents ; and this was universally the case whenever 
both diseases were at the same time epidemic."f A similar 
and still more general observation on the predisposition of 
those who are unaccustomed to impure air, is made by Dr. 
Blane. " Infection," says he, " like some other poisons, does 
not so readily affect those who are accustomed to it, and there- 
fore those who are in the habit of being exposed to it frequently 
escape its bad effects." For the like reason, he adds, " physi- 
cians and nurses are less susceptible than others ; and strangers, 
who are accustomed to a pure air, are the most susceptible of 
any."J With these facts and observations before us, we are 
compelled to conclude, that the impure air necessary to propa- 
gate the contagion does not operate in the manner Dr. Chisholm 
supposes, by " increasing the susceptibility of the system to the 
action of the poison introduced." On the contrary, I believe 
that it produces its effects by some chemical combination with 
the peculiar virus secreted from the diseased body, and that 
thereby the contagion becomes more or less extensively multi- 
plied, according to the extent and virulence of such vitiated 
atmosphere. 

I shall not attempt to define the precise nature of the chemi- 
cal union which takes place under such circumstances. But I 
wish it to be distinctly understood, that in such combination, I 
do not believe, with those writers who contend that a tertium 
quid is produced ; or, as Dr. Adams of London, in his late 



* Chisholm's Letter to Haygarth, p. 182, &c. t Ibid. p. 220. 

X Diseases of Seamen, p. 223. 



208 LECTURE XVI. 

publication on epidemics, has reiterated the same idea, " that a 
new kind of air is generated."* On the contrary, as far as I 
am enabled to view the subject in connexion with the facts usu- 
ally observed during the prevalence of the diseases which have 
been noticed, I am inclined to believe, that in this combination 
the peculiar virus of those diseases is in no way changed, but 
multiplied ; and that this multiplying power is a process very 
analogous to that which we observe to take place in the assimi- 
lation of the fluids of the human body to the peculiar taint 
which may be introduced into the system, as for instance, in 
small-pox and syphilis ; or, perhaps, that it more nearly resem- 
bles the process of fermentation, as it occurs in inanimate mat- 
ter. By both these processes such an assimilation takes place 
in the fluids acted upon, whether of the living body or in dead 
matter, that they partake of the same properties with the virus 
or ferment introduced, and are thereby rendered capable of 
renewing the same process in other bodies under similar cir- 
cumstances. This process has very properly been denominated 
by Dr. Walkerf the assimilating fermentation,J and has been 
no less successfully employed both by him and by Mr. Cruik- 
shank,§ as well as by Dr. Cullen, to explain the changes which 
take place in the living system, acted upon by small-pox, and 
the virus of other contagious diseases, than it has been by Sir 
J. Pringle,|| Macbride,^ and Alexander,** to the phenomena of 
fermentation, as it occurs out of the body. The history of 
plague, dysentery, and typhus fever, as well as the recent ob- 
servations in animal chemistry, furnish a variety of facts which 
may be adduced in illustration of such fermentative process 
taking place in the atmosphere, and in watery fluids loaded 



* Adams on Epidemics, p. 11. 

t Walker's Inquiry into the Small-pox. 

t This assimilating process is, I perceive, adopted by Dr. Good in his late very 
learned work, (see vol. ii. p. 546-7.) "All," says he, "concur in evincing the ex- 
istence of morbid and specific poisons in the blood, acting the part of animal 
ferments, converting the different fluids into their own nature, exciting the com- 
motion of fever, and being eliminated on the surface, as the best and most salu- 
tary outlet to which they can be carried by the very fever which they thus excite." 

§ Anatomy of the Absorbing Vessels. 

|| Diseases of the Army, Appendix. 

IT Experimental Essays. 

** Experimental Essays and Experimental Inquiry. 



CONTAGION, AND ITS LAWS. 209 

with the excretions of the human body, or the vapours of veget- 
able and animal substances in a state of putrefaction. 

Similar facts, illustrative of the fermentative process con- 
tended for, have been observed whenever the yellow fever has 
prevailed in any of the cities or towns of the United States. I 
have already stated, that this disease has always prevailed in 
proportion to the presence of such fermentable materials. It. 
is no less true, that whenever the disease has been introduced, 
it has spread in the greatest degree in those seasons when the 
air was unusually moist : this was remarkably the case in New 
York, in 1795* and 1798,f and in Philadelphia, in 1793 and 
1798 :J and that the yellow fever has prevailed in the United 
States in those seasons when the heat, combined with moisture, 
was most favourable to such assimilating or fermentative pro- 
cess, is also proverbially true. It is also to be observed, as 
universally admitted, that the same disease has uniformly been 
extinguished by the approach of frost, which destroys such fer- 
mentative process. 

Another argument in favour of this explanation is derived 
from the fact, that this disease has, in several instances, been 
introduced into our cities without extending beyond the indi- 
viduals who have introduced it ; manifestly owing to the active 
exertions of a vigilant police, at the same time that every at- 
tention was paid in preserving cleanliness about the persons of 
the sick. This was remarkably the case in the year 1804, 
when the yellow fever was introduced at the Wallabout, on 
Long Island; and in 1809, when the same disease prevailed at 
Brooklyn. In each of those years the fever was introduced 
into this city by -persons who had received the infection on 
Long Island; but, owing to the circumstances just mentioned, 
it was not communicated to others : "while the same disorder, 
owing to local circumstances, spread in the vicinity of those 
places on Long Island where it had first appeared. § 

During the year 1811, the yellow fever was also introduced 
into the city of Amboy, New Jersey, from the Havana, but did 
not spread beyond those persons who were first attacked in 

* See Bayley on the Yellow Fever of 1795. 
t Hardie on the Yellow Fever of 1798. 
t See Rush and Carrie. 

§ American Med. and Phil. Reg. vol. ii. p. 95, &c 
19 



210 LECTURE XVI. 

consequence of their immediate exposure to the air of the in- 
fected vessel. The local circumstances of Amboy, its elevated 
situation, its dry and sandy soil, its wide streets and spacious 
houses, their distance from each other, and the remarkable 
cleanliness of the town, most satisfactorily account for the sud- 
den extinction of the disease, while the evidence of its importa- 
tion must be admitted to be conclusive.* 

But there is another circumstance which particularly merits 
attention. In every epidemic visitation of the yellow fever, 
several days, viz. from eight to twelve, or fourteen, have gene- 
rally elapsed between the first cases that appeared, and the 
communication of it to other persons, even in the same neigh- 
bourhood : insomuch that not only our citizens, but our physi- 
cians themselves, have been led to doubt the existence of the 
disease, and to stigmatize as alarmists those who first announced 
the deadly visiter. I can never forget the occasion, in 1795 ? 
when that venerable and experienced physician, the late Dr. 
John Bard, assembled the physicians of this city to announce 
to them the first cases of this disease which he had observed 
in the family of his friend, Mr. Jenkins. The physicians met ? 
but declared they had seen no other fevers than what they had 
been accustomed to observe every year, and even doubted, on 
that occasion, the correctness of Dr. Bard's observations, rela- 
tive to the nature and character of the disease to which he 
called their attention : but that accurate observer had been too 
familiarly conversant with the yellow fever as it appeared in 
New York in 1743 and 1762, and too well knew the pathogno- 
monic symptoms of that disease, to confound it with the fevers 
of our own climate : he, accordingly, in the most emphatic 
language, replied to their doubts; "Gentlemen, within a fort- 
night you will all see and acknowledge the West India yellow 
fever to exist in our city." The event is well known.f The 
same interval between the first cases of the disease, and its 
subsequent diffusion in the neighbourhood where it first made 
its appearance, is noticed by almost every writer who has re- 
corded the yellow fever in the United States. 

* See American Med. and Phil. Reg. vol. iii. Also, Edinburgh Med. and Surg. 
Journal, and the Med. and Phys. Journal of London. 

tSee Bayley and Hardie on the Epidemic of 1795.. See also Currie on the 
Fever of 1799. 



CONTAGION, AND ITS LAWS. 211 

A similar interval has been frequently noticed in the history 
of the plague. Dr. Russel, in his account of the plague of 
Marseilles, in 1720, observes, " that from the 12th of June to 
the 23d there was a deceitful pause, during which the popular 
apprehensions began to subside. The physicians were re- 
proached with ignorance in having mistaken ordinary fevers 
for the plague. The disease, however, in this interval, had 
continued to spread in the Rue de l'Escale, w-here it made its 
first appearance."* 

It has also been remarked of the plague, as well as of the 
yellow fever, that the infection spread most rapidly when the 
atmosphere was not only heated and loaded with moisture, but 
when it was least agitated by wind or thunder-storms. During 
those calms, w T hen the air may be said to be relatively at rest, 
it has been uniformly remarked, that the contagion of the yel- 
low fever has multiplied itself most extensively, as was always 
very apparent by the greater number that were seized within 
five or six days after such close weather had been observed, all 
which circumstances certainly conspire to promote the ferment- 
ative process that has been contended for. 

This is not all : whenever the yellow fever has been intro- 
duced into the cities of the United States, its first extension has 
always been slow and gradual. Upon several occasions its 
boundaries have been accurately defined by our board of health. 
This, as I have stated on a former occasion, was remarkably 
the case in this city in 1805. The disease, in that year, was 
confined, for some weeks, to a small portion of the eastern side 
of the city, and, as stated by the board of health, " not a case 
occurred in any part of the town, that was not referrible to 
that as its source.'*f This fact being ascertained, the board 
accordingly forbade intercourse with the infected portion of our 
city, and ordered an abandonment of that part of the town, 
threatening violent measures if their orders were not immedi- 
ately complied with. In a short time after, the infection ex- 
tended a few streets further ; the board of health again defined 
its limits, and again declared that still not a case had occurred 
that could not be traced to this part of the city as its source. 



* History of the Plague. 

t Hardie's Account of the Malignant Fever of 1805. 



212 LECTURE XVI. 

Will not the same assimilating or fermentative process 
furnish the most satisfactory solution of the fact noticed by 
Boerhaave, Cullen, Lind, Russel, and many others, that fomites 
are more to be dreaded than the excretions alone proceeding 
from the diseased body? Not, however, in the manner those 
authors suppose, that such fomites acquire greater virulence ; 
but, that by the same process, the specific poison has been more 
extensively multiplied by means of the atmosphere and foul ex- 
cretions which are involved in the clothing worn by the sick ; 
that by the same means the danger of the infection has been 
increased in the same degree that the poison has been multi- 
plied. As a further evidence, too, that the contagion is 
multiplied, but not more concentrated, as those writers have 
imagined, it is a fact established by every writer on those con- 
tagious diseases, that the first cases of every epidemic are 
uniformly the most fatal ; but that, as the season advances, the 
danger of taking the disease is increased, while the disease 
itself has, perhaps, become even milder than it was in the com- 
mencement. 

Let me further ask, do not the processes lately introduced 
for disinfecting the air by means of the fumes of the acetic 
acid, the oxygenated muriatic acid gas, the nitric and sulphuric 
acid vapours, operate by making new combinations with some 
of the ingredients constituting the tainted atmosphere, and 
thereby decomposing the morbid compound 1 According to 
Dr. Crawford, " the fluids which destroy the foetid odours most 
speedily are those which are acknowledged to contain the 
greater portion of oxygen, and it is, therefore, extremely pro- 
bable that this change depends on the union of the oxygen with 
animal hepatic gas, or some one of its constituent parts." But 
the explanation which has been offered by the late Dr. Garnett, 
of the manner in which the oxygen thus employed combines 
with the hydrogen gas which holds the morbid secretions in so- 
lution, appears to me the most satisfactory explanation that has 
been given of those phenomena.* 

From these facts I have been led to conclude, 



* Proceedings of the Board of Health of Manchester, p. 40 — 42. Robertson's 
Treatise on Medical Police, vol. ii. p. 127. Robertson's Natural History of the 
Atmosphere, vol. ii. p. 352, 



CONTAGION, AND ITS LAWS. 213 

1st. That an impure atmosphere is indispensably necessary 
to multiply and extend the specific poison constituting plague, 
dysentery, typhus, and yellow fever. 

2diy. That the impurities of the atmosphere do not produce 
their effects in the manner suggested by Dr. Chisholm, by in- 
creasing the susceptibility of the system to be acted upon by 
the peculiar virus of those diseases. 

3dly. That, instead of predisposing the body to be thus acted 
upon, the reverse is the fact ; that the predisposition of those 
who are most exposed to such impure air is less, while those 
who reside in the pure air of the country are most liable to be 
infected when exposed to the contagion. 

4thly. That the impurities of the atmosphere are fermentable 
materials, to be called into action by the specific ferment of 
those diseases, aided by heat, moisture, and a calm state of the 
atmosphere ; and that as far as such atmosphere extends, and 
the circumstances favourable to such fermentative or assimi- 
lating process continue, so far those diseases become epidemic, 
but no farther. 

The same idea of an assimilating process appears to be ex- 
pressed by Lucretius, when, speaking of the contagiousness of 
the plague, he observes, 

" Proinde, ubi se caelum, quod nobis forte venerium, 
Conmovet, atque aer inimicus serpere ccepit 
Ut nebula ac nubes paullatim repit, et omne, 
Qua graditur, conturbat, et immutare coactat. 
Fit quoque, ut in nostrum quum venit denique caelum 
Conrumpat, reddatque sui simile, atque alienum." 

Lucretius, de Nat. Rerum, lib. vi. 

Or, as it has been rendered by that learned surgeon and ac- 
complished scholar, John Mason Good, Esq. 

" But when the heaven of poisonous power to us, 
First moves remote, its hostile effluence creeps 
Slow, like a mist or vapour ; all around 
Transforming- as it passes, till at length, 
Reach'd our own region, it the total scene 
Taints, and assimilates, and loads with death." 

If the view which has been taken of this subject be correct, 
a still more important truth is the result ; that, while by a rigid 
19* 



214 LECTURE XVI. 

and well executed system of quarantine laws, we have it in our 
power to guard against the introduction of the spark that kin- 
dles the flame, we are also enabled, by means of domestic 
cleanliness and ventilation, to extinguish it when introduced. 
For this purpose our magistrates and guardians of the public 
health cannot be too attentive in their police regulations to have 
all noxious materials removed from our streets and our dwell- 
ings ; and, at the same time that they are ornamenting our 
cities by the erection of magnificent buildings, and the intro- 
duction of other important improvements, they should also avail 
themselves of every opportunity which may present of widen- 
ing our streets, and of reserving squares and other pieces of 
ground to be ever kept vacant, as among the most effectual 
means of preserving the health of our citizens, and guarding 
against the propagation of contagious diseases. 

to ni\ct<ryix.ov 'Jgyov a. /utitv iv . 

"Best is Pelasgic empty" 



w r as wisely expressed by the Pythian oracle ; thereby denoting 
that every large and populous city, as well as Athens, should 
have its pelasgics, or vacant pieces of ground, as so many re- 
servoirs of pure air, for the purpose of counteracting the effects 
of contagion when introduced. 



215 



LECTURE XVII 



LAWS OF CONTAGION. 



I beg leave to offer you a few additional observations on 
contagion. 

1. When the air is once tainted, and the peculiar poison ex- 
tended and multiplied, such atmosphere retains the power of 
communicating the disease a long time after the first cases 
have terminated. In confirmation of this fact it may be ob- 
served, that many years since cases of scarlatina occurred in 
the family of Col. B., six weeks after the first cases of the 
disease had disappeared, and the chambers had been white- 
washed and cleansed. Other children of the same family 
coming into those apartments were seized with the same dis- 
ease. In like manner, the air of a town or city will continue 
to communicate the yellow fever, though the infectious parts 
have been abandoned, and no more sick have remained. 

Jackson, in his Account of Morocco, remarks, that " families 
who had retired to the country to avoid the infection, on re- 
turning to town, when all infection had apparently ceased, 
were generally attacked and died." The same thing took place 
during the visitations of yellow fever in the city of New York. 
Too early return, therefore, of the citizens to their homes is to 
be guarded against. 

Hence, therefore, the air becomes the vehicle, though it may 
not be the primary cause of the poison. 

Upon the same principle, too, it is, that fomites, i. e. clothing 
worn by the sick, or other substances of a spongy or porous 
nature, that have been exposed to the air thus contaminated for 
a long time, retain the poison with which they become impreg- 



216 LECTURE XVII. 

nated, and afterwards communicate disease. I have seen the 
cases of some servants in a Mr. O.'s family attacked with 
yellow fever, upon receiving the clothing of a relative who had 
died of that disease in the West Indies — at a time, too, when 
no yellow fever was prevailing in this city. In like manner, 
after the death of the late Gardener Baker, (well known in 
this city as the keeper of the Museum, when it was in the Ex- 
change, formerly in Broad street,) who fell a victim to the yel- 
low fever in Boston ; his clothes were sent in a trunk to his 
wife, resident at Governor's or Long Island. Upon opening the 
trunk and handling his clothing, his wife contracted the same 
disease, although in the pure air of the country, and within five 
days fell a victim to yellow fever, attended with black vomit 
and all its other characteristic symptoms — at a time, too, when 
that disease did not exist in this city, or even upon Long Island. 

Beds, blankets, wool, cotton, from the spongy nature of those 
materials, are ail ready conductors ; and, if in foul condition, 
readily multiply the specific or peculiar poison of the disease, 
whether it be yellow fever, typhus, or dysentery. Not that it 
gives rise to the usual produce of filth or miasma, but the pe- 
culiar disease the person labours under. 

2. Bilge-water, too, is another vehicle of contagion, and as 
containing decomposed vegetable, and sometimes animal mat- 
ter, w T ill often give origin to diseases, as typhus fever and dys- 
entery — analogous to the whale of Forestus, the putrid hides 
at Nevis, and the putrid unburied bodies left on the field of 
battle. There was the case of the Mohawk, in which typhus 
fever was engendered by the accumulated filth of one hundred 
passengers, and perhaps in part from the ofFensiveness of the 
materials floating on the surface of the sea after three days' 
calm in the heat of August, 1794. The atmosphere of a ship 
containing much offensive bilge-water also becomes the vehicle 
of febrile diseases that may be introduced. A ship, from her 
very construction, is peculiarly fitted to harbour and multiply 
such poison, and is scarcely ever after to be freed from the 
poison with which she may have become impregnated. Hence 
the wisdom of the British Board of Admiralty and the Board 
of Health in directing the valuable ship, the Hankey — which 
introduced the yellow fever into Grenada and some of the 
other West India islands, and into Philadelphia in 1793, from 



LAWS OF CONTAGION. 217 

the coast of Africa — to be burned, which was accordingly done. 
See also an interesting description of the construction of a 
ship, as peculiarly calculated to retain the poison of a disease, 
written and published in the American Medical and Philosophi- 
cal Register, by the late Jonathan Williams. But bilge-water 
in itself is not in general the source of fevers in our ports. 
New York, although long distinguished as a commercial city, 
would, in that case, never have known exemption from that 
description of disease. Every vessel that sails would have 
given origin to such fevers. 

The putrid air of Burling-slip proved the vehicle, but was not 
the cause of the yellow fever, when that part of the town was 
devastated in 1791, the year that Gen. Malcolm became the first 
victim, after visiting a ship recently arrived from the West Indies, 
with a corpse then on board of a person who had died of that 
disease. Not that decomposed animal and vegetable matter 
will not engender disease ; on the contrary, dysentery w r as pro- 
duced among the packers of beef when they had occasion to 
empty the cellars in Pearl street and at the Fly-market, of the 
putrid beef, and convey the same into the river. This putre- 
faction was induced by the heavy fall of rain that had preceded, 
and had filled the cellars, in 1798. See Edmund Prior's Letter, 
in the Memoirs of the College of Physicians of Philadelphia. 
The yellow fever also had prevailed in other parts of the town 
previous to the fall of rain; but upon this occasion neither the 
men engaged to remove the putrid beef, nor that tainted por- 
tion of the atmosphere, had been exposed to the poison of yel- 
low fever, which was confined to the Coffee-house slip, and to 
the places of residence of those who imbibed the disease from 
that particular quarter of the town. See Hardie's Report of the 
Fever of 1798. 

3. Foul air in general, I may say, is the vehicle, but not the 
cause ; i. e. it is the vehicle of any peculiar material of disease 
that may be introduced into i*. 

Examples. The foul air arising from the process of filling up 
the Fly-market slip, and that too in the midst of summer, al- 
though it occasioned the inhabitants to close their windows, so 
offensive were the exhalations, did not beget fever. In like man- 
ner, when at another season a similar process was performed 
in Peck slip, yet no yellow fever was engendered. 



218 



LECTURE XVII. 



More recently similar changes were effected in Broad street; 
the drains were opened — the filth they contained was removed, 
and the grounds raised, when many of the inhabitants were com- 
pelled, by the constantly offensive state of the air, to abandon 
their dwellings during that season — yet no yellow fever was pro- 
duced. In these cases the corporation may be considered as 
making a series of experiments to ascertain if it was possible 
to engender such disease — but happily they did not succeed, 
although the season, as it regards all the requisites of heat and 
moisture, was calculated to produce the disease in question, if 
domestic circumstances in this latitude could ever give origin 
to the evil. Another similar proof of the relative innocence 
of such filth as a cause of yellow fever, is derived from the fact 
that in this city, previous to the construction of privies, it was 
the custom to convey the night soil in tubs, and to deposit the 
same on the shores at Coenties-slip and at Whitehall, which 
were then washed with the tides. The place of such deposit 
thence received the name of Rotten-row, which was proverbi- 
ally filthy, but proverbially healthy. Some of our then oldest 
citizens considered it a salutary, almost a refreshing practice, 
to snuff the breezes passing over those deposits of filth. After 
the burning of the city, too, in 1775, the cellars of the dwellings 
that had been consumed were made use of as fit places for de- 
posites of a similar nature, but without producing disease in our 
city- See my Appendix to Thomas's Practice. In like man- 
ner I well remember within the heart of our city, at the foot of 
Frankfort and of Ferry streets, a marshy piece of ground, 
thence denominated the Swamp, in which similar deposits took 
place ; but however annoying by their odour to the inhabitants, 
they produced no disease — no yellow fever. 

More recently, tan-yards, morocco manufactories, and slaugh- 
ter-houses, occupied the same vicinity, and are still at this day 
existing in some of the thickly settled parts of this city, but 
which are remarkable for their healthy condition, even in the 
greatest heat of season. The inference, therefore, inevitably 
follows, that putrid air is not essential to the production of con- 
tagious fevers, though so considered by some. Hence it was 
that the slaughter-houses were removed from Paris to the Isle 
des Tygres. See Gent. Mag. for 1764. Also, Quarterly Rev. 
Oct. 1814, p. 58. And that it is not necessarily the cause, 



LAWS OF CONTAGION. 219 

though it serves to convey and multiply the poison. This fact 
was originally remarked by Lucretius of the plague of Athens, 
that such poison when introduced, creeps slowly, assimilating 
the air to itself. His line shall be my motto. 

" Taints, and assimilates, and loads with death." 

The manner and nature of this ferment we have already en- 
deavoured to explain. This is confirmed by the fact, that at 
many of those parts of the town, at other seasons, when the 
air was undisturbed, and less foul, and less offensive, fever has 
prevailed, but only when manifestly introduced by a diseased 
individual or some imported fomites, and to which the disease 
was to be distinctly traced. 

It is, too, to be observed, that the yellow fever has only be- 
come more prevalent since a better police has been introduced 
into our city ; but it is also to be added, that it has become 
more frequent since our commerce has become more extended 
to the West Indies and to the tropics. Let us also recollect 
that during the embargo, when all intercourse with the tropics 
was suspended, we enjoyed a perfect exemption from that 
scourge of our sea-ports, and that, too, throughout all the cities 
in the union. A general state of health prevailed a-s long as 
embargoes and non-intercourse continued. 

Again : were it possible that such animal and vegetable de- 
composition should be the source of the pestilential forms of 
fever, instead of being confined to our cities, the country too 
would in like manner be affected. Every hog-pen, every cow 
or horse-stable, every tan-yard, would be the parents of plague 
and of yellow fever. 

5. Another observation deserving our notice, and w r hich 
shows the distinction between the operation of ordinary putrid 
materials on the constitution, and the peculiar poison engender- 
ing fever of a pestilential nature, is, that the materia febricalis, 
as remarked by Fordyce and others, to be frequently without 
smell, manifesting no sensible effluvia ; it is known to produce a 
very peculiar and strong impression on the person attacked, in 
some cases producing a deliquium — in others, nausea and vomit- 
ing; — in some, stupor, mania, and even death itself, have been the 
effect of the deleterious operation which such poison produces 



220 LECTURE XVII. 

upon the sensorium. Accordingly, Thucydides, Russel, and 
others, have related the fatal effects of plague as occasioned by 
this invasion of the disease ; and that in every such endemic 
visitation persons have fallen down dead on the streets. Similar 
facts have been recorded of the effects of the poison producing 
yellow fever in this city, and in Philadelphia in 1793, 1795, 1798, 
&c. It has happened, too, frequently, that persons seized in this 
city with yellow fever were instantaneously conscious of re- 
ceiving the peculiar virus into their constitution. Dr. Richard 
Bayley, Dr. Malachi Treat, Dr. Ledyard, Dr. Benjamin De- 
witt, all health officers, and who fell victims to the disease, 
were conscious at the instant of the attack, of the reception 
of the poison during the performance of duty. The two for- 
mer did not believe, when they entered upon their duties, that 
the yellow fever was propagated by the medium of contagion. 
Dr. Richard Bayley stated to his assistant, Dr. Joseph Bayley, 
while returning from visiting a ship at quarantine, that he never 
before experienced a similar sensation, and that he was then 
sensible that he had contracted the disease prevailing on board 
said ship. He died of black vomit a few days after. 

Dr. Treat, in 1795, upon returning from his official visit on 
board the Zephyr, from Port-au-Prince, and which had lost many 
of her crew with yellow fever, was seized with vomiting while 
on board, and on his way home stopped at the house of the 
Rev. Dr. M'Knight, (see M'Knight's letter in the American 
Med. and Phil. Reg.,) and afterwards at Mr. Clason's dwelling, 
and requested some brandy and water to compose his stomach, 
alleging to them that he was certain, from his extraordinary 
sensations, such as he never before had experienced, that he 
had taken the yellow fever from that ship. His anticipations 
were too true — he died in three or four days from that time, 
with the characteristic symptoms of that disease. 

Mr. Concklin, of Huntingdon, Long Island was also con- 
scious of his attack, went to Long Island and communicated 
the disease to his family, and to the connexions who attended 
them. The disease was pronounced yellow fever by Dr. Udall, 
of that vicinity, who had been familiarly conversant with yel- 
low fever in the West Indies. See his communication to me 
in the Medical and Philosophical Register. We do not yet 
know the nature of the gas constituting even miasma, (see Sey- 



LAWS OF CONTAGION 



221 



bert,) nor the particular fluid even produced by putrefaction ; 
and still less are we acquainted with the composition of the 
peculiar conditions of atmosphere making up the various forms 
of pestilential fluids. 

The atmosphere is composed, according to the analysis of 
the chemist, of seventy-two parts of nitrogen, twenty-seven of 
oxygen, and one of carbon. From the analysis made of the 
fluids produced by the putrefaction of animal substances, ac- 
cording to Troostwyck and Dimond, two German chemists, we 
learn that their ingredients are the same as those composing the 
common atmosphere, but in different proportions, viz. sixty-three 
of azote or nitrogen, and thirty-seven of oxygen ; and that this 
additional proportion of oxygen renders such atmosphere more 
virulent in its effects, and productive of disease, forming the 
gaseous oxyde of nitrogen. The same view has been adopted 
by Dr. Mitchill, and constitutes w T hat he denominates septon. He 
hence was led to recommend the various alkalies as the means 
of disarming the septous acid of its malignant qualities. The 
Doctor adduced in its favour the beneficial effects of lime-water, 
as prescribed with good effects in yellow fever. He also con- 
sidered the long exemption of Lisbon from that disease, as owing 
to its houses being constructed of limestone. But Lisbon be- 
came at last the seat of that disease. In this, then, the Doctor's 
hypothesis failed him. But this was not the most unfortunate 
event that befell the doctrine of septon. Carmichael Smyth, un- 
luckily for the Doctor, but happily for the benefit of mankind, 
discovered that the great antidote to contagion was the very 
gas that Dr. Mitchill considered as the parent of contagion 
— the cause becoming the cure. It w r as for this discovery that 
he received the rewards of Parliament in two large sums of ten 
thousand pounds sterling each ; and that, too, notwithstanding 
the opposition that was made by Dr. Trotter, who, having been 
an army physician, was also desirous of at least a part of the 
loaves and fishes given to Carmichael Smyth. The Medica 
Nautica was published with the view to defeat the success of 
Smyth ; and for the purpose of giving all possible force to his 
opposition, he summoned to his assistance the doctrines and 
views of Dr. Mitchill, but in vain. The contagious fever of 
Winchester was arrested in its progress by Smyth, and the re- 
ward was accordingly bestowed, notwithstanding the theories 
20 



222 LECTURE XVII. 

of Drs. Trotter and Mitchill combined. Besides, it is a well 
established fact, the discoverers of the gaseous oxyd of nitro- 
gen breathed that air without the evils ascribed to it — another 
truth militating against the doctrine supported by Drs. Trotter 
and Mitchill. 

But although we do not know the constituent qualities of 
the fluid of the contagion, as unfolded by chemical analysis, 
we know what it is not, and we know some of its laws. We 
know that it is not hydrogen gas, as let loose by the solution of 
the metals in acids (and which Pilatre de Rozier, in his experi- 
ments with Mr. Shaldon, of London, could respire without even 
the noxious effects it usually produces.) It is not hepatic gas, 
as extricated by acids from hepar sulphuris, the sulphuret of 
potash ; nor is it fixed air, carbonic acid gas, as from the vat 
of the brewer, and from the Grotto del Cani, or from calca- 
reous substances as detached by the various processes of che- 
mistry; and we have seen that it is not nitrogen gas, nor even 
the nitrous oxide ; but it is usually considered as made up of 
some of these variously combined. 

6th. An observation also meriting attention is, that the con- 
tagion of any disease is not communicated to all who may be 
exposed — that all do not contract a contagious disease, even 
though exposed to it when in its most virulent state. This we 
see exemplified in small-pox. Some are never known to take 
it naturally, or even by inoculation, however frequently it may 
be repeated. So with syphilis — many escape, though frequently 
exposed to it. When the small-pox prevailed in the ship of war 
the Royal George, as stated by Lind, out of eight hundred and 
eighty persons who had never had it, nearly one hundred es- 
caped. The disease, too, terminated in the ship before their 
arrival in port. A case related by Dr. Walsh, is also in point. 
A person who had been inoculated frequently — who had slept 
with many ill of small-pox — who had inoculated his own serv- 
ants on his estate, took it at last himself, when at an advanced 
period of his life, and died of it. It may be added, that this 
is generally the case with persons who contract the disease in 
advanced life, that they sink under it. Yet sometimes, in 
fevers, seven of nine exposed have been affected by the conta- 
gion. Fordyce, p. 120. We know that they are so communi- 
cable, depending on predisposition, viz. as season of the year, 



LAWS OF CONTAGION. 223 

habit of body, climate, purity or impurity of the air — but not 
by the predisposition noticed by Dr. Chisholm. Such is the 
mysterious nature of the material producing febrile disease, 
and such is the general manner of its communication. This 
leads us to inquire into the origin of contagious diseases. 

1st. Of some, the history is not known as to their origin ; as 
small-pox, syphilis, &c. 

2d. Some are generated in the system, de novo — and in this 
way are frequently engendered, although in their progress they 
acquire the peculiar circumstances of propagating themselves 
by contagion. Examples of these are typhus fever and dys- 
entery, the effects of putrid animal and vegetable decompo- 
sition, whether in or out of the body, as the whale of Fores- 
tus, living on animal diet, fish, &c. 

3d. Some proceed from concentrated human effluvia, as jail 
fever, as at the Oxford assizes. See Camden's Britannia. See 
Sir John Pringle. See Stowe's Chronicle. 

The secretions of the skin are noxious, as appears by a che- 
mical analysis of their properties, which have been detailed. 
If they are injurious to the individual when retained, surely 
the carbonic and azotic materials secreted from the lungs and 
skin of many are still more offensive and noxious, and thence 
fever may readily be induced as the consequence; and that, too, 
where cleanliness may be otherwise observed. 

Fordyce relates the case of four persons riding in a coach 
half a mile with a person from an apartment in which numbers 
had been confined for several months, yet were kept clean from 
putrescent matter. The four died of malignant fever. For- 
dyce, p. 115. Still putrid air is favourable to its diffusion — 
but we see fevers generated without it, merely by our own 
effluvia, when concentrated. In our own jail in this city, in the 
summer of 1811, a number were taken sick with the typhus 
fever, proceeding from this source. And more recently it has 
been engendered by a great number being crowded together in 
the same manner in our penitentiary and alms-house, and 
rendered not only a malignant disease, but readily communi- 
cable to those who visited the establishments. 

Similar facts are of frequent occurrence on board of ships 
crowded with passengers, as the Irish ships coming to this 
port with the sons of St. Patrick, especially in the hot seasons 



-24 LECTURE XVII. 

of the year, and in warm latitudes. We see typhus fevers in 
great numbers thus produced, filling our hospitals. 

Nor is this disease confined to the human species ; it extends 
to sheep and hogs. The effluvia from sheep are a source of fe- 
ver, which readily spreads by contagion among healthy flocks. 
Dr. Bard's flock of sheep was thus materially injured by intro- 
ducing among them sheep recently arrived from Europe, which 
had become diseased on the passage by fevers generated on 
board, the effects of confinement. They had been selected in 
Europe from healthy flocks, but by confinement on ship- 
board, even before leaving the harbour, were attacked with 
fever, not merely an ordinary sheep fever, but a ship fever. 
With sheep in a peculiar manner such fever is produced, not 
merely from their fleece and the heat it accumulates, but from 
the peculiar oily nature of the secretions, the yolk as it is de- 
nominated. 

Hogs also are liable to contagious fevers, but less frequently 
than sheep, for the reason just mentioned. Contagious dis- 
eases are generally said not to be communicated from one 
species of animal to another — nor to men on ship-board. For- 
dyce, p. 113. We well know that the variolous matter is 
said to be confined to man — but there are exceptions. In Dr. 
Bard's flock, an eruption like small-pox made its appearance, 
and which possessed all its properties. The vaccine virus is 
also a well-known exception, as appearing in the grease of the 
horse, upon the teats of the cow, and thence fortunately com- 
municated to the human species. Hydrophobia, too, is com- 
municated from the dog, the fox, the cat and the rat, to man. 
So, in like manner, has the contagion of yellow fever and the 
plague been communicated to cats, dogs, and other animals. 
Dr. Rush, although in his last years he had his doubts of the 
contagious character of yellow fever, published in his account 
of the endemic in 1793 several cases of the disease affecting 
other animals as well as man. The influenza, too, he has 
recorded as affecting various animals besides the human 
species. Dr. Rush, had he lived, would, I verily believe, have 
returned to his former faith in the contagiousness of fever, as 
lie had done with regard to religion. At one period, he varied 
his religious creed several times. He was Quaker, Anabaptist, 
Presbyterian and Churchman, alleging that change was the 



LAWS OF CONTAGION. 225 

characteristic of the human mind, and that God alone was 
immutable. So in medicine : — during one of my visits to him 
in the last years of his life, I submitted to him my views of the 
qualified contagiousness of yellow fever. When he returned 
it to me he observed, " Doctor, you and I can now shake 
hands, and unite nearly in the same doctrine" — or words to 
that effect. 

To return from this digression. In like manner, 4thly, The 
peculiar poison of yellow fever is generated in the northern 
man, when transported to the heat of the tropics, especially in 
Africa, in the West Indies, and South America. It is not 
necessary to go to Siam, or even to Africa, for this disease, as 
many writers have done. A peculiar form of fever is so pro- 
duced by a tropical sun, when acting upon the northern 
constitution, — not engendered by putrid animal or vegeta- 
ble matters. Chisholm has abundantly disproved the first of 
these supposed sources of yellow fever. See his communica- 
tion. And Dr. Stuart has clearly demonstrated that the 
most offensive of vegetable matters, accumulated masses of 
the husks of coffee, will not produce a yellow fever. See his 
letter to me during his visit to this city. Such atmosphere, 
loaded with putrid miasms, doubtless prepares the system to 
become more violently affected by the disease, and to give 
wings to the contagion, by becoming assimilated to the pecu- 
liar poison introduced into it. It is no objection to the conta- 
giousness of those diseases, that they are engendered afresh. 
Puerperal fever in Aberdeen, Edinburgh, and in the confined 
dwellings of the poor, assumes this virulent form, and is ren- 
dered communicable. Not so in private life, where ventilation 
and cleanliness exist in the chambers of the sick. Even inter- 
mittens become malignant fevers, under particular circum- 
stances. AH fevers, says Dr. Fordyce, are infectious, p. 110. 
Dr. 'Gregory, in his lectures, when I had the honour of being 
his pupil, most earnestly inculcated the same doctrine, which 
is doubtless correct. In the Edinburgh Review you find the 
same views entertained. In Minorca, says Cleghorn, inter- 
mittents assume this character, when of long duration, in a 
hot climate or a hot season, and in bad air ; i. e. the more the 
system is vitiated, the greater is the tendency to the typhoid 
form of fever. Fordyce remarks, that fever is never thus 
20* 



226 LECTURE XVII. 

communicated (from person to person,) when consisting of but 
one paroxysm only ; i. e. it requires duration to produce all 
the necessary changes in the habit, to give to the disease its 
contagious character. Fevers, by whatever cause they may 
have been produced, under the circumstances mentioned of 
duration or atmosphere, may become contagious. But putrid 
matter is not in all instances essential, though it is favourable 
to the origin, and especially to the propagation of febrile dis- 
ease. " Even in the body," says Fordyce, " contagion in fe- 
vers is engendered without signs of putrefaction in the blood, 
in the solids, or in the secretions." Fordyce, p. 117. 

Although fever may frequently be attended with signs of 
such putrefaction, and be thus rendered more malignant, yet 
frequently without those appearances it becomes capable of 
reproducing by contagion the same disease. The matter, 
therefore, constituting contagion is different from the product 
of a putrefactive process; i. e. it is a peculiar secretion from the 
diseased body, it is a peculiar compound, not yet developed by 
the chemist. But although we know not its composition, if 
we have attained to some of the more important laws which 
govern its communication, we make some advance that 
cannot fail to prove interesting to humanity, and especially to 
this country, in which the high temperature of our summer 
seasons render them at least the temporary nurseries of pesti- 
lence. 

I may here remark, that although heat is favourable to the 
propagation and the continuance of yellow fever in this coun- 
try, as being similar to that which gave it birth in the tropics, 
yet in some other diseases it is less favourable to the propaga- 
tion. The plague is of this description ; it is suspended by in- 
tense heat, in the same manner as yellow fever is terminated 
by frost. The contagion even of the small-pox is destroyed 
by the regular blowing of the hot winds of Patna ; so says 
Dr. Shoolbred, in his observations contained in vol. xiii. p. 224, 
of the Medical and Ch. Review. The cow-pock poison is also 
diminished by heat; hence it becomes difficult to communi- 
cate the disease in hot weather. This concludes our view of 
the exciting causes of yellow fever, as well as of fevers in ge- 
neral. In our next, we shall proceed to the investigation of the 
proximate cause of fever. 



227 



LECTURE XVIII. 



THE PROXIMATE CAUSE OF FEVER 



We now come to the consideration of the proximate cause 
of fever. 

What is a proximate cause 1 According to Aretaeus, the 
proximate cause of a disease was known only to the gods — 
by less pious inquirers, ingenious speculation has been exer- 
cised, and substituted for established and solid principles. Dr. 
Gregory answers, " quae prsesens, morbum facit," &c. Have 
we then such a cause apparent in what we have seen of the 
phenomena of fever 1 And is it necessary to the cure of fe- 
ver that we must know its proximate cause ? 

Pringle, Lind and Cleghorn, you will tell me, have given us 
no proximate cause of fever; yet their works communicate 
more facts directing the treatment of fever, and less theory, 
than almost any other w r riters in medicine. I grant it ; and I 
acknowledge still more — that their treatment of fever, too, is 
the best, and the most successful, being the result of their ex- 
tensive observations and experience. Yet this is no objection 
to legitimate deductions, or a correct theory. On the contrary, 
such principles, at the bed-side, are of immense importance. 
They not only lead us with firmer step, and with more confi- 
dence, in the prescription of remedies, but they extend our ho- 
rison — they lead to more enlarged views — they give us a wider 
range in the use of remedies, or the means of carrying those 
principles into practice, and they enable us to combine our 
forces to meet the enemy, instead of the feeble skirmishing that 
results from the want of a well-digested plan of operation. 

Were Dr. Cullen's views of the proximate cause correct, 



228 LECTURE XVIII. 

making debility the cause of fever, then tonics, in all their forms 
and varieties, would constitute the means of cure : so if the 
doctrine entertained by others, who trace every fever to a pu- 
trefaction of the fluids, were true ; then the most industrious 
use should be made of antiseptics, both internally and exter- 
nally administered. 

Again : if we resolve fever into irritation, it leads to the most 
active employment of all those means which are calculated to 
subdue and control such inordinate excitement, wherever it 
may appear, whether in the agitations of the nervous system, 
or in the disturbance of the blood-vessels, or as it proceeds 
from the condition of the circulating fluids, or perhaps all com- 
bined. It is therefore of infinite importance to obtain those 
principles of practice to which we are led by our knowledge 
of the proximate cause of disease ; for without those principles 
as our guide, our practice becomes limited, and, in some re- 
spects, empirical. The investigation of the proximate cause of 
fever has accordingly exercised the talents of the most eminent 
medical writers, from the earliest records of the art to the pre- 
sent day ; and the opinions which this investigation has given 
rise to, are not only numerous but contradictory; and they are 
sometimes so entangled and involved with extraneous matter, 
that it is frequently difficult to discover in what they really 
consist. It will be a subject at least of some curiosity with 
most of you, to know what have been the views of our prede- 
cessors with regard to the proximate cause of fever. I will 
endeavour in a few words to bring the most important of them 
under your view, and as briefly as possible to develope the prin- 
ciple on which they rest. It will at least serve as an outline 
for those who may be disposed to extend their researches far- 
ther on this subject. 

1. Hippocrates, as the first known writer on the healing art, 
is the first who has delivered an opinion respecting the material 
cause of fever. 

The works that bear his name are numerous, but there is 
reason to believe that they were not all written by him that are 
ascribed to him. In that case we are not surprised that there 
should be some variety in the views and modes of expression 
in different parts of his writings. Hippocrates may be consi- 
dered as the founder of the doctrine which traces diseases to 



THE PROXIMATE CAUSE OF FEVER. 229 

the fluids ; and febrile diseases he considered as proceeding 
more especially from the morbid conditions of the bile in par- 
ticular. 

" The greater number of fevers," says Hippocrates, " pro- 
ceed from bile." At this we are not surprised, after the view 
we have taken of the effect of fever upon the secretions, and 
especially as it affects the biliary organs. He accordingly 
makes four species of fever, as depending on the quantity and 
the quality of the bile ; denominating them synochus or con- 
tinued fever, quotidian, tertian, and quartan. The synochus or 
continued form of fever he considers as proceeding from the 
greatest quantity of bile, and in the least mixed state. This 
form of fever, too, he observes, terminates in the shortest space 
of time ; there being no respite from the excessive heat, the 
waste of body is proportionally rapid — soon melted down, 
is the meaning of his expression. Judging from the climate 
in which he prescribed, and the predominance of bilious dis- 
charges, we have great reason to presume that the type of fe- 
ver to which he refers must be the common bilious malignant 
fevers of hot climates, not unlike that with which we have 
been visited. 

The quotidian is next in degree to the synochus, and, ac- 
cording to him, proceeds from the next greatest quantity of 
bile ; and inasmuch as it proceeds from bile in smaller quantity 
than in synochus, and has a remission, so it is of longer dura- 
tion, and the body is not so soon worn down. So of the ter- 
tian form : it proceeds from a still smaller quantity of bile, has 
a longer remission, and a longer duration. 

The quartan follows a similar rule, and is the most tedious ; 
for he observes, there is less bile to keep up the heat, and there- 
fore it has the longest remissions. But this is not all : in the 
quartan, he considers the bile as not only less in quantity, but 
changed in its quality ; for in this case he remarks, that the 
form of fever is owing to black bile, which is the most tenacious 
and adhesive of any of the humours " within the circumference 
of the body," and is not easily disengaged. Hence he infers the 
longer duration of a quartan fever. This operation of fever, 
according to its character, whether continued or intermit- 
ting, upon the different secretions, is to be looked for. When 



230 LECTURE XVIII. 

symptoms, therefore, are mistaken for causes, we are not 
surprised at the distinctions made by Hippocrates. This is 
the fullest and most accurate view of the theory of fever to be 
found in the writings of Hippocrates. 

In another part of his works he introduces secondary causes 
or qualities, to be conjoined with the bile, such as the bitter, the 
acrid, the salt, and other qualities. In like manner he notices 
the excessive flow of bile to the liver and to the head, as addi- 
tional sources of disease ; but bile constitutes the essence of 
fever, although it may be modified by the circumstances w T hich 
have been mentioned ; and to those he adds cold, as also hav- 
ing some agency in the production of fever. 

2. Erasistratus considers fever to consist in a transfusion of 
red blood into the arteries or air-vessels, in consequence of re- 
pletion. The circulation of the blood, it is to be recollected, 
was not understood at that time — the arteries being supposed, 
in a state of health, to contain nothing but air, seeing that they 

. are empty when they fall under the examination of the anato- 
mist. Erasistratus supposed the blood to be all naturally lodged 
in the veins, and that the cause of inflammation, and many 
other diseases, depended upon the blood getting from the veins 
into the arteries. 

3. Asclepiades was a professed medical innovator. He sup- 
posed health to depend upon the just proportion between the 
pores of the body and the small particles they are intended to 
receive or convey ; and that when these pores are obstructed, 
and the corpuscles cannot pass through them, disease is pro- 
duced. The dryness of skin, and other evidences of obstruc- 
tion, very naturally favoured this view. Proceeding upon this 
principle he accordingly recommended his patients, ill of a fe- 
ver, to ride on horseback, for the purpose of removing the 
obstruction which he supposed to constitute the cause of the 
disease. He is said, too, to have been the first who prescribed 
wine for his patients, and to have indulged them in all their in- 
clinations. From all these circumstances, these novelties of 
practice, and his opposition to the reigning doctrines of Hippo- 
crates, he acquired unprecedented reputation. With these 
views of disease he thought it necessary, among other things, 
to new model the theory of fever. He accordingly defines it 



t* 



THE PROXIMATE CAUSE OF FEVER. 231 

to consist in excess of heat, and increased force in the pulses 
of the artery. That the quotidian, and other forms of fever, 
are modified by various corpuscles or atoms obstructing the 
pores of the body ; and according to the size of these corpus- 
cles, and the size of the pores they obstruct, disease was pro- 
duced. In other words, according to the obstruction of the 
surface, or the dryness of the skin, was the degree and charac- 
ter of the fever that ensued, — a doctrine in a great degree 
true, though strangely expressed. Here is, in other words, the 
doctrine of spasm. 

4. Themison, the founder of the Methodic sect, and a pupil 
of Asclepiades, also gave origin to some new opinions ; or ra- 
ther, so modified and extended those of his master, as to give 
them a new shape, insomuch that he is regarded as the author 
of that doctrine which refers fever to a constriction or spasm of 
the smaller extreme vessels, so much afterwards insisted upon 
by Hoffman and by Cullen ; for Hoffman's doctrine is expressly 
that of capillary constriction, followed by a corresponding re- 
laxation, and a third, or mixed state: — in other words, Brunon- 
ianism — and which, as you perceive, is the opposite of the 
humoral pathology. Themison, as you may suppose, with 
these Brunonian notions of spasm and relaxation, must have 
been an unsuccessful practitioner. He was so much so, that 
Juvenal says of him, 

" Quot Themison aegros autumno occiderit uno ?" 

But we could scarcely anticipate any other result from a 
practice founded upon such erroneous and narrow notions oi 
pathology. Not that stricture or spasm does not exist, but that 
an exclusive view to that, as the source of disease, must be so 
limited that it supplies us with few or no principles of action. 

5. Athenseus, who was the head of another sect, the Pneu- 
matics, (so called from their admission of a fifth element or 
spirit governing the system — not content with the four ele- 
ments of the Greek philosophers,) according to the testimony of 
Galen, appears to have ascribed the cause of every form of 
fever to a " putrescency in the mass of the humours." This 
doctrine was afterwards revived in the morbific or peccant 
matter which Sydenham considered as present, and to consti- 



232 



LECTURE XVIII. 



lute every form of fever ; and that the excitement of the sys- 
tem was no other than an effort of nature to destroy it, by con- 
veying the poison producing it out of the body. This may be 
considered, in some degree, a revival or modification of the 
doctrine of Hippocrates. 

6. Galen, who is the most voluminous writer, and the most 
fertile in imagination, of all the ancients, has discussed this 
subject at great length. Although his views are often entangled 
and obscure, his opinion is still prominent on this subject. Fe- 
ver, according to Galen, is present when heat in preternatural 
quantity is communicated to the heart ; i. e. that the existence 
of preternatural heat does not constitute fever, unless it be com- 
municated to the heart. He moreover adds, that the generic 
differences in the heat, and which are three in kind, take their 
character from the difference of the matter on which the febrile 
heat acts, and which manifests its effects primarily on the body 
of the heart itself, on its juices, or on its moving power. But 
Galen considered this heat, and the fever proceeding from it, 
to have some variety in its origin. In some cases he supposed 
it to originate in motion ; in others, from putrefaction ; and 
by communication of foreign or external heat, in a retention 
of the heat that is ordinarily extricated from the body, or 
from the application of actually hot substances. Of continued 
fever, he considered the cause to be, as it were, immured, and 
contained within the veins. He furthermore considers the quo- 
tidian form of fever to have its origin in putrescent phlegm ; 
i. e. that, in other words, adapted to the present state of medi- 
cine, in that form of fever which most nearly approaches to 
the continued form, the circulating fluids of the system are 
most affected, and are most apt to assume a malignant or pu- 
trescent character. So far, then, you see this idea is of very 
ancient date. 

The other forms of intermittent fever, viz. the tertian and 
the quartan, Galen referred, as Hippocrates has done before him, 
to the vitiated condition of the bile. The tertian he believed 
to be produced by a yellow bile, and the quartan by a black 
bile. In other words, as this latter type of fever recurs so sel- 
dom, (every fourth day,) it has less effect on the biliary organs ; 
hence the bile is of a darkish colour ; i. e. fresh bile is not se- 
creted, as in the quotidian, or in fevers of a continued type. 



THE PROXIMATE CAUSE OF FEVER. 233 

The Arabian physicians did little more than transcribe the 
opinions of their predecessors. Upon this subject, as in most 
other branches of medical science, they are mere copyists. 
Avicenna, who is the best known and the most distinguished, 
and who has treated medical subjects more in detail than any 
other of the Arabian physicians, defines fever to consist in pre- 
ternatural or adventitious heat excited in the heart, and thence 
communicated to the rest of the body by means of the spirit 
and blood contained in the arteries and veins ; in other words, 
a preternatural degree of heat extended throughout the system. 
Such are the principal opinions, on the cause of fever, that are 
to be met with in the writings of the ancient physicians. Some, 
you perceive, are altogether ideal ; while the greater number 
of them consist in the appearances or symptoms which fever 
exhibits, as the effect of diseased action. The increased secre- 
tion of bile, its various qualities and appearances, the increased 
heat of the body, the putrescency of the system, the constric- 
tion, the obstruction of the surface, are all to be considered as 
symptoms or effects, and not the proximate cause of fever. 

8. Paracelsus and his followers exerted themselves in opposi- 
tion to the Galenical and other doctrines of the ancients, relat- 
ing to the nature and cure of fever. But the greater number 
of the attempts are so ridiculous and absurd as scarcely to de- 
serve the slightest notice in this place. 

The introduction of chemical reasonings, in the imperfect 
state of chemical science at that time, constituted indeed the 
acme of medical romance, for no whim was too extravagant 
to be employed in the explanation either of the operations of life 
and health, or of the phenomena of disease. Although flashes 
of light were occasionally produced, as the result of these 
labours, they were but of momentary duration, neither perma- 
nently enlightening medicine, nor contributing to the purposes 
of general science.* 



* Paracelsus supposed the body to be a composition of salt, sulphur, and mer- 
cury, and that diseases proceeded from changes wrought in these ingredients. 
And, after Paracelsus, chemistry was employed to explain most of the phenome- 
na of the human body, and the nature of diseases. The solution of the food in 
the stomach was ascribed to an acid. Muscular motion was accounted for by 
the effervescence of an acid and an alkali in the rhomboidal receptacles, which 
the anatomist supposed to exist in the muscular fibre. The heat of the body 
21 



234 



LECTURE XVIII. 



Next succeeded the incorporation of the mechanical and 
chemical doctrines ; but this combination led to no satisfactory 
solution of the origin and causes of fever. 

9. The imaginary lentor and viscidity of the blood with 
which it was supposed the smaller vessels are crowded, and 
which, by the -resistance to the circulation that they thus cre- 
ated, gave rise to fever, arose from this union of the mechani- 
cal and chemical doctrines, and which afterwards constituted 
the celebrated system of Boerhaave, and the theory of Stahl 
too in part. It was assumed without any evidence of its ex- 
istence, with the exception of the dense, inflammatory crust 
that appears upon blood drawn in fevers, and which has ever 
been matter of triumph to the believers in this doctrine — found 
too, in all fevers — on this account, favourable to their views on 
this subject. 

10. The next view of the subject that offers any thing ori- 
ginal or deserving notice, is found in the writings of Van Hel- 
mont — a man of an ardent and enthusiastic make of mind — 
distinguished for his genius and his penetration, and who held 
high rank as a physician. " Febrile heat," according to Van 
Helmont, " is the product of the effort of the irritated archeeus, 
(another term denoting the sentient principle or sensorial 
power,) and the radix of fever is actual peccant matter." So 
that fever and febrile heat result from Archseus himself, inflamed 
by the strenuous effort which he makes to expel something that 



they explained by the mixture of the acid of the chyle with an oil or balsam 
they supposed it to meet with in the blood, analogous to the heat and inflamma- 
tion excited by mixing acids with essential or distilled oils out of the body. Fe- 
vers and other diseases were ascribed to the same or similar agents. The cold 
fit of an intermittent fever was accounted for by the mixture of nitre or sea salt 
with the blood, because those substances generate cold by mixture with water 
out of the body. The epidemic fever at Ley den, in 1669, which proved fatal to 
more than two-thirds of the inhabitants of that city, Sylvius de la Boe, then 
professor at Leyden, ascribed to an acid, and attempted to cure by alkalies and 
absorbents. The great fatality of that disease is ascribed, at this day, in some 
degree to the injudicious and inert practice which the chemical notions of Syl- 
vius gave rise to. We, too, have had our Sylvius's (de la Boe.) In this city, in 
1798, the same doctrine was revived and published by our learned Professor of 
Natural History, Dr. Mitchill, who considered the yellow fever of that season to 
be occasioned by an acid, and accordingly recommended alkalies and absorbents 
as its means of cure. See his Tract on the Nitrous Oxyd of Azote. Also Med. 
Repository. 



THE PROXIMATE CAUSE OF FEVER. 235 

is offensive. This, therefore, may be considered as another 
expression of the vis medicatrix naturae of Campanella, Syden- 
ham, and others, and even of the autocrateia of the celebrated 
Stahl, who maintains " that all fevers may be regarded as ef- 
forts or designs of the vital motions secreting and excreting, 
instituted, directed, and carried into effect by nature herself, 
for the preservation of the individual." 

There are other opinions to be found in the writings of the 
eighteenth century, but 

11. That of Hoffman, the celebrated professor at Halle, in 
Saxony, is the most important. Hoffman was a man of great 
learning — of much experience and observation — of compre- 
hensive genius, and of great apparent candour. " The funda- 
mental cause of fever," according to Hoffman, " is a spasmo- 
dic affection of the whole nervous and fibrous system, which 
proceeds principally from the spinal marrow, and extends in suc- 
cession from the exterior to the interior parts." This, you will 
perceive, however, is but a revival of the atomic doctrine of 
Asclepiades, or of his pupil, Themison, on the spasmodic con- 
striction of the capillary vessels of the skin. The very same 
doctrine was afterwards adopted by 

12. Dr. Cullen, but who proceeded a step higher than his 
predecessor Hoffman had done, by prefixing a link that he 
supposed was wanting to establish a regular series of cause and 
effect, Dr. Cullen believing that Hoffman had only noticed 
the effect, and had overlooked the cause. This Dr. Cullen be- 
lieved he supplied by premising certain sedative powers, which 
operated by producing debility ; and that this debility begot the 
spasm ; and that this spasm begot the fever. It reminds me 
very much of the house that Jack built ; so I believe, will the 
history of Dr. Cullen's fabric remain as a tale to be recited 
more for the gratification of curiosity, than to serve any really 
useful purpose in the practice of medicine. Like the supposed 
morbific matter of Athenseus, and afterwards of Sydenham — 
like the viscidity and lentor of Boerhaave, and the obstructions 
of other authors, so of the debility of Dr. Cullen — they are all 
to be considered rather as the effects than the causes of fever. 
Morbid matter, doubtless, as you have seen in our enumera- 
tion of the remote causes of fever, is occasionally, nay, fre- 
quently, an exciting cause of fever; and in the advanced stage, 



236 LECTURE XVIII. 

or typhoid state of the system, is unquestionably a part of the 
proximate cause of fever, as far as such vitiation of the body 
as we have seen, can become the cause of the secondary fever 
which we have noticed. But it is not the proximate cause of 
all fevers, nor present in every case of fever. When a materia 
febricalis, that gives origin to fevers, as contagion, is present 
in the system, it is a remote cause, but does not constitute the 
proximate cause, as it was considered by Sydenham. It was 
upon this belief that the supposed ebullitions and fermentations 
which constitute the doctrines of Sydenham, were conceived 
necessary to throw off such morbific matter — analogous to the 
eruptions we see take place in small-pox and measles, and to 
the petechia?, the carbuncles, and biles of plague ; and which, 
in many instances, are critical eruptions in those diseases. In 
like manner, the eruptions on the skin, and those which ap- 
pear about the mouth, are also apparently favourable to the 
same idea ; but they very readily admit of a different solution. 
These eruptions serve to convert a general into a local disease, 
and in this way are so salutary ; for the same thing is the con- 
sequence of blisters and other local stimulants, the effect of art. 
The evacuations by stool, by urine, by sweat, in like manner 
prove critical ; but they may be useful, and equally so, in re- 
moving fever, without carrying out morbific . matter. Such 
matter, however, I have said is frequently an exciting cause of 
fever ; but that in typhus fever it constitutes even a part of the 
proximate cause. In these cases, then, the doctrine of Syden- 
ham is, to a certain degree, applicable ; and is more generally 
true in fevers than is usually admitted, except that it can hold 
no place but in the typhoid state of the body, where, by the 
causes enumerated, the mass of fluids partakes of the diseased 
action. But with regard to the supposed sedative powers- — 
the debility of the consequent spasm of Dr. Cullen's system, 
which has been so generally received, it must be acknow- 
ledged that debility sometimes precedes fever ; but in that case 
it is only a predisposing cause, by increasing the susceptibility 
to the action of the exciting causes. Hence, too, we see the 
typhoid state of fever afterwards induced by the same predis- 
position; but we see no evidence of debility invariably pre- 
ceding fever, though accidentally so, as after a debauch or 
intemperance ; but we see irritation, restlessness, and other 



THE PROXIMATE CAUSE OF FEVER. 237 

symptoms of great disturbance in the system, constituting the 
first stage, but which are not to be considered as debility, though 
debility may follow. Again : we see diseases of the greatest 
debility, as dropsy, paralysis, atrophy, and no fever the effect. 
We all see great debility in the last stage of fever, and still 
greater than under any other circumstances after the fever has 
terminated ; yet no relapse, as after long, tedious typhus : 
whereas, at that time, if debility was the proximate cause, the 
fever should return with ten-fold violence. My conclusion from 
these facts is, that debility has nothing to do with fever; that is, 
not essentially so. Nor are the remote causes necessarily debi- 
litating or sedative in their first application ; they are only so in 
their ultimate consequences ; they do not operate in time to pro- 
duce the debility Dr. Cullen talks of in the first stage. They 
come too late. Besides, on the contrary, the remote causes 
are, for the most part, not debilitants, but excitants, giving even 
temporary strength instead of debility — as exercise, heat, cold, 
miasma, contagion, spirituous liquors. These are all'for the most 
part exciting causes. His doctrine therefore of debility, as a 
cause of fever, is purely hypothetical. So also, says his editor 
and friend Dr. Rotheram, but without giving us a better. Still, 
as I have said before, error must be first investigated before we 
can arrive at truth. Let us then agree almost to banish the term 
debility ; it invests the subject with a cloud that totally obscures 
the truth. This is not all, it misleads the practitioner, insomuch 
that Armstrong very properly denominates it " the fatal doctrine 
of debility." He goes on to remark, " that the speculations of 
Cullen and other men of genius, which have so long obscured our 
pathological views, are at length passing away, like clouds before 
the spreading light of more favoured times ; and we may rea- 
sonably hope will soon entirely disappear from the horizon of 
the medical world." p. 132. "Debility has been pitched upon 
as the cause of this, and of other dropsies — the bugbear debi- 
lity — the Circe of fevers, which has been more hurtful to suffer- 
ing humanity than earthquakes to the physical world — a name, 
and that name all a lie, has too often been the innocent cause of 
conducting numbers to the tomb." Dawson's Nosology, p. 132. 
From the view we have taken of the symptoms of fever 
throughout its progress, from its invasion to its termination — 
from the nature of the remote causes, including both the pre- 
21* 



238 LECTURE XVIII. 

disposing and exciting causes, and the operation of those causes 
upon the system, I am led to the following conclusions relative 
to the proximate cause of fever. That it appears to me to re- 
solve itself into irritation, which manifests itself first in the 
brain and nervous system. This is an essential ingredient in 
the construction of fever. 

2. Showing itself in the muscular or moving fibre. This again 
appears (1.) in the larger muscles, showing itself in the heart 
and larger vessels : showing itself, 2dly, in the smaller arteries, 
in the exhalent and secreting vessels, in the absorbent system : 
and 3dly, as a consequence of such irritation, producing a viti- 
ated or diseased condition of the circulating, secreted, and ex- 
creted fluids of the system. In other words, irritation of the 
nervous and moving fibre — not of the nervous fibre exclusively, 
(for in that case the disease would be one of those denomi- 
nated nervous, belonging to the class neuroses) — but includ- 
ing the muscular as well as the nervous fibre. This is the 
only legitimate conclusion that the phenomena we have seen 
will justify; and the only deduction which the nature or the 
operation of the remote causes will sustain. Such I consider 
to be the deduction which flows from the foregoing facts. This 
view of it will "he found, I trust, important, as leading to cor- 
rect principles in practice. The indications which are deduced 
from the proximate cause of fever, corresponding with this 
view, are, 

1st. To counteract the irritation which more especially ap- 
pears in the nervous system upon the invasion of fever. 

2d. To counteract the excitement of the nervous and mus- 
cular fibre, as it subsequently manifests itself in the vascular 
system. 

3d. To remove the vitiated state of the fluids which exists 
in the last stage of fever, or as it appears rather in the second- 
ary form of fever, denominated typhus, or typhoid. This state 
of the fluids keeping up this stage of fever, (the fever ceasing 
upon its disappearance,) is properly, in such cases, to be con- 
sidered as constituting a part of the proximate cause of fever, 
inasmuch as this state of the system is the cause of a renewed 
excitement both in the nervous system and in the blood-vessels. 
The indication to which it gives rise might perhaps have been 
included in the first two, as it might be embraced among the 



THE PROXIMATE CAUSE OF FEVER. 239 

means of removing the irritation of the blood-vessels and 
nervous system. But as this stage of fever exhibits a totally 
new train of phenomena, and calls for special treatment, cal- 
culated to counteract the diseased condition of the fluids, as 
well as to act upon the solids, I have concluded to make it a 
distinct indication. This arrangement, too, is better suited to 
the bed-side ; for the physician, when called to the sick room to 
see a patient ill of fever, has, in this case, three primary and 
distinct questions to ask himself. 

1st. Is this the invasion of fever? My prescription is ac- 
cordingly manifest. 

2dly. Is it the more advanced state of intermittent, or is 
that excitement ended ? And, 

3dly. What is the state of the system in other respects 1 Is it 
pure debility that remains ? or has it ended in a diseased state 
of the fluids in general ; and is such diseased state the result 
either, 1st. Of simply long continued action'? as we see some- 
times to occur in inflammatory diseases when protracted, as in 
peripneumony. 2dly. An original febrile taint in the habit? 
3dly. Of a vitiated atmosphere? 4thly. Of the heat of climate 
or of season ? or, 5thly. Of a habit vitiated by bad diet, intem- 
perance, hardship, or long-continued previous diseases of an- 
other character ? This arrangement, in my opinion, dissects 
and simplifies that complex subject, fever, and places in a con- 
spicuous light the proximate cause, to the removal of which 
the physician is to direct ajl his attention and skill. 

If I have erred in any of my premises, or in the conclusions 
to which I have been led, I am not conscious of such error ; 
but shall be greatly obliged by any corrections or objections to 
the doctrine I have advanced, that any of the ingenious youth 
whom I now address may suggest. I invite the most free dis- 
cussion on this interesting subject. It will be instructive to you, 
and gratifying to me ; and I assure you, it will be no less grati- 
fying to me, at all times, to correct error than to establish truth. 



240 



LECTURE XIX. 



THE GENERAL TREATMENT OF FEVER.— TREATMENT OF THE 

FIRST STAGE. 



The treatment of fever now falls under our consideration ; 
and, as in describing the phenomena of fever we divided 
it into its different stages, we shall observe the same order 
in speaking of its treatment, pointing out, as far as may be 
practicable, the remedies proper to be employed in the different 
stages of fever. At this time I propose, therefore, to point out 
the general indications of cure, the general means of fulfilling 
those indications, and the principles upon which those means 
are to be employed. 

In the treatment of the first stage, constituting the invasion 
of fever, the first indication, as we have remarked, agreeably 
to our view of the proximate cause, is to counteract the irrita- 
tion, which appears more especially in the nervous system. 
Dr. Cullen's indication, agreeably to his view of the proximate 
cause of fever, ought to be to counteract his supposed debility; 
and accordingly, bark and wine, with other tonics and stimuli, 
would be the best remedies ; but neither his doctrine, nor the 
treatment it leads to, I trust, will be contended for. The irrita- 
tion we have noticed as existing in the first stage, or rather as 
constituting the first stage, shows itself in various ways. The 
symptoms which usher in the first stage of fever may be divided 
into three classes. 

The first class we may denominate the ordinary attack of 
fever, exhibiting itself perhaps by a slight chill and some sense 
of coldness, but without much pain or any other symptoms, 
local or general. 



TREATMENT OF FEVER. 241 

In the second class, we find the patient attacked with severe 
pain, showing itself in the head, back, or limbs, or in all at the 
same time, with great general soreness and stricture of the 
surface — a distressing sense of coldness amounting to rigors 
or perhaps convulsions. These rigors are sometimes fatal, 
especially to aged persons ; but Dr. Cullen remarks, that rigors 
taking place, the patient is not carried off by that paroxysm. 
This is not always so. I recollect the case of a gentleman who 
was thus attacked with rigors upon the invasion of a paroxysm 
followed by stupor, and which proved fatal to him during that 
very paroxysm — the irritation was such that they ended in an 
apoplexy; such was the crowded state of the vessels of the 
brain. He was subject to intermittents, and they usually 
affected his head. He had been exposed to the cause of it ; it 
occurred during the season of its prevalence, and from the 
rigors and general symptoms which ushered it in, the character 
of the disease was not to be doubted. This event too, I believe, 
is of much more frequent occurrence than is usually supposed ; 
it might be called the apoplectic state of intermittents. 

The third class of symptoms we find still more formidable 
and alarming, viz. delirium or mania ; for all fevers, as we 
have seen is the case with yellow fever and the plague, are 
not ushered in by the ordinary chill that usually announces 
the paroxysm of an intermittent. 

In the ordinary attack of fever, the heat generating power 
of the system is sufficient to counteract the temporary effects 
of the irritation produced upon the extreme vessels, for the tone 
of the system is not impaired, nor are any of the vital organs 
particularly oppressed. In that case, the constitution being 
good, and the body not more than ordinarily cold, the common 
practice is generally sufficient, viz. to place the patient com- 
fortably warm in bed, and to administer to him some warm 
tepid drinks, as various teas or toast water.* Weak mint or 



*Let me here remark, once for all, that the proper mode of making toast or 
bread water, is by infusing- the slice of bread, when well browned, in boiling- 
water, but not in cold water, as it usually is done ; for the object is to give the 
drink moderately warm, and to render it grateful to the nauseated stomach ; to 
do so, this is the only proper mode of preparing this drink, and thus prepared, it 
is one of the most palatable and grateful drinks to patients in general that can 
be directed in an irritable stomach, at the same time that it is readily obtained. 



242 LECTURE XIX. 

catmint tea, when they can easily be procured, are preferable 
drinks when the stomach is disturbed during the invasion of 
fever. They should, however, be taken of moderate strength, 
as they may otherwise, by the essential oil they contain, 
increase the excitement of the system ; the quantity too should 
be regulated by moderation, for we may excite the system by 
the quantity as well as the quality of the drinks we employ. I 
frequently also direct the patient previous to his getting into 
bed, if his extremities be cool, to bathe the feet in tepid water.. 
I then give him a moderate sudorific anodyne, composed 
of 3ss. of the spiritus mindereri, with from fifteen to twenty- 
five drops of laudanum. If the stomach is irritable, administer 
the dose in mint water. 

It is important, however, to remember that the hot stage of 
fever is very soon to succeed. Keep this always in view in 
all your prescriptions. On this account, too, observe the tem- 
perature of the water in which the patient immerses his feet, 
of the drinks he employs, and the temperature of the air of the 
room. With the same view the quantity of his bed clothing 
should also be regulated by the physician, and all stimuli, such 
as light, noise, company, business, should be withdrawn or 
guarded against at this time, in order to prevent or moderate 
the excitement which is soon to succeed. 

But one of the most important and efficacious class of reme- 
dies which can be administered at the invasion of fever, (espe- 
cially the remittent and continued forms of fever,) when the 
situation of the patient is such as to call for or to justify their 
use, is emetics. Armstrong, a late writer, p. 99, observes that 
" in the beginning of almost all febrile complaints, emetics will 
generally be found very beneficial, though much neglected 
now-a-days by many practitioners." The emetic having ope- 
rated, I usually direct some Indian gruel, either sweetened with 
brown sugar, or seasoned with a small quantity of common 
salt, to be taken afterwards, with the view to obtain some effect 
from it upon the bowels ; in some instances, an hour or two 
after the emetic has ceased to operate, I add the sulphate of 
magnesia, or the sulphate of soda, or Rochelle salts to the gruel, 
or solicit an evacuation from the bowels by an enema, or a 
dose of Seidlitz powder. 

In the first stage, where it occurs under ordinary circum- 



TREATMENT OF FEVER. 243 

stances without those peculiar distressing impressions upon the 
nervous system ; without the inordinate fulness of the blood- 
vessels producing delirium, stupor, or mania; where the degree 
of cold is not excessive ; where the patient is neither too 
plethoric nor of too feeble a habit, nor too advanced in life, 
when the circulation of the brain is less active, and the vessels 
of the brain are perhaps loaded by the venous plethora ; when 
these circumstances do not forbid their use, emetics, and these 
given so as to produce full vomiting, may be directed with the 
best effects. In some instances, too, the breath of the patient is 
offensive, the tongue is foul and loaded with sordes ; he com- 
plains of a disagreeable taste in his mouth ; in such cases, 
whether in the adult or child, they are peculiarly proper, espe- 
cially if the fever may have habitually returned for several 
days, or there is reason to suspect some additional source of 
irritation about the stomach or biliary organs, in such instances 
they cannot be too promptly administered. But not so in stupor 
or feeble old age, nor in yellow fever, are they to be adminis- 
tered. 

What are the effects of emetics, that they are so generally 
serviceable in fever 1 

In the first place, they empty the stomach of its contents; 
not only of indigestible food, but oftentimes of an inordinate 
quantity of mucus and other materials which may be accumu- 
lated in that organ. They promote the secretions of the sto- 
mach, and of the adjacent viscera, particularly the liver. They 
increase the serous discharge of the intestines, and by the 
relaxing and antispasmodic effects on the whole system, they 
restore the perspiration, and unlock most of the secretions and 
excretions of the body. The emetic I prefer in such cases, and 
with the view to these general febrifuge effects, is composed of 
ipecac, and antim. as follows: Ipecac, x. gr. to xv. gr., combi- 
ned with tart, antimony, ij. gr., directing the patient to take 
little or no drink until it has operated ; to be repeated, if neces- 
sary, in half an hour, or an hour if it has begun to operate. 

For the removal of the second mode of attack, where the 
patient suffers much pain, a great sense of soreness, or is affect- 
ed by rigors or convulsions, such remedies are indicated as 
will most immediately diminish irritation, and particularly such 
remedies as are best calculated to allay spasm. Opiates, the 



244 LECTURE XIX. 

warm bath, and tepid drinks, must be had recourse to, and 
are among the best remedies we can employ for this purpose. 
Opiates are useful by diminishing sense and motion. 

To children I administer ten drops of laudanum every 
half hour, in conjunction with the tepid bath. In the adult, 
thirty drops with 3ss. of the sp. mind, may be repeated every 
half hour, until the nervous system be composed. If the 
stomach be much disturbed, warm mint water will be the best 
vehicle for the laudanum. A general warm bath, as soon as it 
can be procured, ought also in such cases to be employed. In 
the mean time, however, the limbs may be wrapped up in 
fomentations composed of vinegar and water, one-third or 
one-fourth vinegar, and two or three parts water, but not 
spirituous fomentations; as before, paying attention to the 
temperature at which they are applied, lest more mischief than 
good arise from the manner of their application. It is no less 
important too, in applying them, as far as possible to prevent 
the clothes of the patient, and the bed and bedding, from be- 
coming wet with the application made use of, as the patient 
afterwards is rendered liable to a chill from the cold and 
moisture surrounding him. For this purpose, then, be careful 
to introduce one fold of the blanket between the legs of the 
patient and the bed he lies on. Let his limbs then be sur- 
rounded by the wet flannels with which the fomentation is 
applied, and another fold of the blanket that is beneath him 
turned up, so as also to protect the clothing that is above him 
from becoming wet and uncomfortable. Another ready and 
common mode of applying steam or vapour to the body, and 
one to which the elder Dr. Bard was attached, is by means of 
bricks heated to a proper temperature. These should be sur- 
rounded first by a flannel cloth wet with a mixture of vinegar 
and water ; and in order to prevent the bed from being made 
wet and uncomfortable, this should be again surrounded with 
another piece of dry flannel. Two of these bricks thus pre- 
pared, and laid to the extremities, or at the sides of the patient, 
will be found useful both in restoring warmth, and inducing 
that greatest febrifuge of all, perspiration. And we may observe, 
that the temperature of the body is much more reduced by 
perspiration than augmented by the heat that is thus applied in 
conjunction with moisture or steam. So, in like manner, the 



TREATMENT OF FEVER. 245 

effects of the warm bath in producing a large discharge from 
the surface, more than counteracts all the heat that has been 
applied in the bath. But as I have before remarked, you can- 
not, as a general rule, be too particular in your directions 
relative to the temperature of all the internal or external appli- 
cations that may be necessary in the treatment of fever at this 
stage. 

But again: in old men much affected by cold and rigor, their 
caloric carried off, the patients feeble and not in condition readily 
to restore the lost heat, and the heat perhaps abstracted by 
long previous exposure to cold; in that case stimuli may be 
administered, and are indicated. But even then they should be 
directed with some caution. Respice finem should still be our 
motto. Cordials and aromatics are improper in most cases of 
the invasion of fever ; but in those which I have just mentioned, 
in which the system is feeble, the action in the extreme vessels 
can only be restored by stimuli, administered both internally 
and externally. Warm and stimulating drinks, such as gin or 
brandy toddy, spiced wine, or wine whey, should now be 
freely administered, until the temperature of the patient be 
restored. With the same view, other stimulants may be 
prescribed; as a tea-spoonful of compound spirits of lavender, 
frequently repeated, or twenty or thirty drops of the vinous 
spirit of ammonia, or of the aq. ammonias. 

External applications should also be directed, as a hot bath, 
made still more exciting by the addition of rum, or the aq. 
ammon. occasionally introduced while the patient is immersed 
in the water. Stimulant spirituous fomentations — stimulant 
cataplasms, prepared by dipping a slice of toasted bread in hot 
vinegar, and covering the same with mustard, may be applied 
to the soles of the feet, or other sensible parts of the body. 
The room too should be rendered warm, the patient covered 
with rather more than the ordinary quantity of clothing, with 
the view to accumulate heat about his person. But remember, 
all these stimuli are again gradually to be withdrawn, in pro- 
portion as the excitement of the system becomes restored, 
or may be increased; otherwise these very means of restoring 
the heat and circulation will be the means of exciting a high 
and dangerous degree of febrile actron. 

But when the third mode of the invasion of fever comes on 
22 



246 LECTURE XIX. 

with delirium, stupor, or mania, a method of treatment is called 
for totally different from that used in the ordinary attack, or 
in that accompanied with great coldness, severe pain, rigors, 
or convulsions. In this third mode of invasion no cold stage is 
perceptible ; it at once comes on with stupor, delirium, or the 
ravings of mania. In that case, if the pulse be full and slow, 
or hard and frequent, and the habit of body plethoric, as is 
frequently the case even in advanced life, we must have recourse 
to depletion. Not opium in this case ; not, however, for the 
reason that perhaps some of you may give, because it proves a 
direct stimulant to the system ; no, but because it retards the 
action in the smaller vessels, and thereby crowds the larger. 
Do you want the proof of this ? You have ocular demonstra- 
tion of it in the experiments made by Dr. Monro upon frogs. 
You also have it in the experiments made by Dr. Bard upon 
himself — see his thesis. But if it be not the property of a seda- 
tive to diminish sense and motion, then opium may be called a 
stimulant ; and if it be the property of the stimulant to excite 
sense and motion, then opium is assuredly sedative. 

But to return. Evacuations by the lancet, and perhaps by 
cupping, or by dividing the temporal artery, if the symptoms 
be urgent — by cathartics, blisters, and sudorifics, (such as 
cream of tartar, sp. mind., &c.) to diminish the quantity of cir- 
culating fluids, which especially oppress or irritate the brain, 
must be employed. The vital functions being thus attacked, 
the most active measures become necessary. 

In the 188th No. of the Medical and Physical Journal, this 
practice is recommended as a new practice ! and announced 
as a great discovery ; and lately the same practice of blood- 
letting has been recommended in the treatment of typhus by 
Walsh of Edinburgh, and by Dr. Armstrong in his late work 
on the same subject, as a novel treatment. Venesection in 
intermittents, and in typhus, is a doctrine which has been well 
understood and practised in this country for many years, and 
taught in the University of Pennsylvania by Dr. Rush, and in 
this college. I also taught it in the very first lessons I ever 
delivered on the treatment of fever. All light does not pro- 
ceed from the east. I had almost said, that Dr. Rush alone has 
done more towards introducing an efficient practice in the treat- 
ment of diseases, than all his cotemporaries in Europe or any 



TREATMENT OF FEVER. 247 

other parts of the world collectively have done. But caution 
is no less necessary in discriminating between those cases 
where such active treatment is called for, and those where it is 
inadmissible; we otherwise may extinguish life instantane- 
ously, for fever in this invasion is sometimes immediately fatal. 
But again; do not suffer the life of your patient to be sacrificed 
in this apoplectic form of fever for the want of the lancet, 
because forsooth it is symptomatic of the invasion of an inter- 
mittent, in which blood-letting in general is not advisable or 
necessary. Venesection, in the cold stage of an intermittent, 
has been lately recommended in the Edinburgh Journal, as if 
a new practice. It has been long since well understood in the 
United States. Be cautious, too, not to commit yourselves by 
denominating this form of fever apoplexy, for your patient in a 
few hours may be relieved, and the want of discrimination in 
you be censured for not foreseeing this result. 

Purges, in like manner, are generally improper in the first or 
cold stage of fever. So also, are such drinks as cream of 
tartar and tamarinds, &c, but they are not improper in the 
present state of stupor or phrenitis; they are now indicated. 
And recollect, too, that cathartics are not only indicated for 
the purpose of diminishing the fluids of the system, but also to 
transfer excitement from the brain, and thereby also to lessen 
the quantity of fluids there determined by such irritation. 
With this view, saline cathartics, or stimulant cathartics, com- 
posed of jalap and calomel, are to be preferred. I cannot, 
however, too severely reprobate the use of the small doses of 
calomel, usually and promiscuously prescribed under the appel- 
lation of fever powders ; they are indeed fever powders, for 
they most effectually continue fever. Calomel, as a cathartic, 
in the beginning of fevers, is among the best that can be em- 
ployed, and occasionally too, may be administered in the pro- 
gress of the fever. It excites a degree of nausea, sometimes 
vomiting; unloads the biliary organs, dislodges scybala, invites 
a large secretion into the intestines; and afterwards, in unison 
with antimony, has a sensible effect upon the surface, as well 
as the excretory organs in general. Such purgatives as excite 
the whole system, as does colocynth, gamboge, &c, are to be 
avoided. This is where cathartics are indicated to empty the 
intestines, and thereby to prevent the absorption of the contents 



248 



LECTURE XIX. 



of the belly, which, as a means of repletion, would aggravate 
the disease, while by their quality they would add to the ma- 
lignancy of such fever. Castor oil is frequently prescribed as 
a domestic purge in the beginning of fevers ; as a means of 
emptying the intestinal tube it is effectual, but not so in its 
operation upon the liver, or the excretions of the general 
system. Enemata are also indicated, as more immediate in 
their operation than cathartic medicines. 

In the treatment of fever it frequently becomes necessary to 
combine all your forces, and as nearly as possible at the same 
time, and not in the successive and inefficient manner that we 
see remedies often directed. Such procedure is similar to that of 
a commander who suffers his army to be cut off, regiment by 
regiment ; whereas, by one general engagement he might have 
been sure of victory, and that with a small loss of his men. 
Thus in fevers the powers of life are gradually destroyed by the 
continuance of the disease, and the many repeated, feeble and 
insufficient attempts in succession to bring about a cure — 
whereas, by summoning all your resources at the same time, 
you put the enemy to flight, and prevent that loss of strength 
that otherwise would be the result. We should not wait in 
such cases for the slow operation of cathartics, and which 
are rendered still more slow by the influence of the fever upon 
the system, but immediately administer the domestic injection, 
by which you will remove a great additional source of irrita- 
tion from the bowels. Take oil, molasses, or honey ; common 
salt, aa gss. ; water Ife.i. M. ; or equal parts of milk and wa- 
ter ; or soft soap, 3ii., water ifej.; or which is still more active, 
castor oil, 3s., glauber salts, gs., aq. pluvial, ifei. M. 

Blisters are another means of diverting the excitement from 
the brain to the surface of the body, not by the mere discharge 
of fluids they occasion, but by the excitement they produce 
upon the surface, or to the part to which they are applied. 
Such, too, is the opinion of Dr. Jackson, that they produce their 
good effects by the local affection they create.* Armstrong, 
too, highly approves of blisters, as among the means of break- 
ing up febrile action. But even the derivation of the fluids in 
these cases is useful, by abstracting them from the brain to 

* Jackson on Fevers, 224. 



TREATMENT OF FEVER. 249 

which they tend, and the sooner blisters are applied the better. 
They should be applied behind the ears, between the shoulders, 
to the wrists, to the ankles, or to the praecordia; that is, to the 
most sensible parts of the body, for the very purpose of creating 
new and powerful excitement. 

Sudorifics also constitute an important class of remedies in 
this stage and state of fever — that is, such sudorifics as at the 
same time that they relax the surface of the body, also 
diminish excitement in general. The sp. mindereri — aq. 
acetat amm., may be advantageously combined with a por- 
tion of tart, antimony. Antimony, in some of its forms, espe- 
cially tartarized antimony, the tartrite of antimony and potass, 
gr. ij. in eight doses, w T ith cream of tartar, 3ij-, or in sweetened 
water alone. Vin. antimoniale, xxx. gtt. to 3i., the pulvis an- 
timonialis, that is, the antim. calc. phosph. gr. iv. to gr. vi. 
every two hours, in syrup. The real James' powder, from 
gr. x. to gr. xv. or 9i. every two or three hours, or com- 
bined w^ith calomel, from gr. iij. to gr. vi. of each com- 
bined, repeated every three hours. These diaphoretic or 
sudorific medicines should also be aided in their operation by 
suitable drinks. When the patient is in the use of antimonial 
medicines, his drinks should be some of the following : toast 
water, catmint tea (nepeta cataria,) balm tea (melissa officina- 
lis,) common tea (thea viridis,) bran tea, rice or barley water. 
But when the patient is not in the use of antimonial medicines, 
he may make use of other drinks, which he will find both more 
grateful and useful during the heat and thirst of fever, as 
lemonade, apple water, tamarind water, currant jelly and wa- 
ter, molasses and water with the addition of a small quantity 
of vinegar ; this is commonly called switchell by our eastern 
brethren, and a most excellent drink it is too in fevers, unless 
the bow r els may be too freely opened. It is frequently directed 
by me in the hospital. Vinegar whey, too, is another valuable 
drink in this excited state of the system ; but these acid drinks, 
taken during the use of antimonial medicines, are frequently 
attended with pain in the bowels, and in some instances they 
render those medicines dangerously active. They should give 
place, therefore, to some of those before enumerated. 
22* 



250 



LECTURE XX. 



THE GENERAL TREATMENT OF FEVER.— TREATMENT OF THE 
SECOND STAGE. 



The treatment proper to be pursued in the second or hot 
stage of fever, is now to be noticed. This stage may, with 
great propriety, be denominated a state of simple excitement ; 
that is, as opposed to the heat and complicated excitement 
which most frequently appear in the typhoid state of fever. 
The symptoms which indicate the high excitement which 
marks the second stage of fever, now to be noticed, have al- 
ready been minutely described, viz. the frequent and hard pulse ; 
respiration hurried ; the heat increased ; the skin hot, flushed, 
and dry ; the eyes loaded, especially the adnata ; the excreting 
surfaces shut up ; the tongue white, dry, but not foul, as in 
typhus fever ; belly costive ; urine high coloured ; the menses, 
as well as the other excretions, affected, for the most part 
diminished; but if flowing, excessive. Yet notwithstanding 
all these evidences of high excitement, there is no proof or 
symptom denoting the putrescent state of the body called 
typhus. It is therefore a state of high excitement simply. The 
system is under the impulse of violent action in every part of 
it. The indication in this state of things, therefore, is apparent ; 
viz. to lessen the excitement in the vascular as well as the nerv- 
ous system, more especially in the former. The means of ful- 
filling this indication are, 

I. By venesection, general and local, and by both, if a local 
determination to the head or throat should make it necessary : 
but in the use of the lancet, or of local blood-letting, whether 
by cupping or by leeches, we should keep in view the character 



TREATMENT OF FEVER. 251 

and ordinary termination of the fever for which we prescribe. 
We should know if it be pure synocha or inflammatory fever, 
or if only the second stage of an intermittent, or if it be the yel- 
low fever, typhus fever, puerperal fever, scarlet fever, or spotted 
fever ; all which have different terminations, and exhibit differ- 
ent types, according to the local circumstances under which 
they present themselves. These are questions always to be 
asked and answered before we prescribe ; that is, we must look 
to the remote cause as well as the proximate. Dr. Caldwell 
wonders why Dr. Cullen should enjoin this subject of attention; 
for he asks, What can this have to do with the indications of 
treatment ? I say, this should always be kept in view as gov- 
erning us in the use of all the remedies we are to employ, at 
least as it regards the extent to which they are to be directed. 
But in all these diseases the lancet may be employed, and may 
be necessary, if the excitement be excessive ; for in all it has 
occasionally proved serviceable. But as to the degree to which 
it may be carried, we must decide from circumstances ; such 
as the nature of the remote cause, the prevailing diseases, the 
climate, the season of the year, the habit of the patient, the 
time of life, and other circumstances — as the appearance of the 
blood drawn — I mean as it regards its consistence, its dark co- 
lour, the force with which it flows — but not the buffy coat, so 
constantly but so fallaciously made the test of the necessity of 
blood-letting. On the contrary, Dr. Huxham, Manning, and 
Dr. Rush, all describe the buffy coat as met with in most ma- 
lignant fevers, and sometimes in the advanced stage, when it 
had not appeared upon the blood drawn in the first. This re- 
mark is expressly made by Dr. Rush in his work on yellow 
fever. " In rheumatism, when cured by bark," Dawson (p. 163) 
remarks, that " in all the cases prescribed for by Morton, Hulse, 
Fothergill, and Haygarth, the buff increased after every vene- 
section." In like manner, in the advanced stage of phthisis, the 
same appearance is observed. The buffy coat, therefore, can 
be no guide as to the use of the lancet. 

II. Another means of reducing the excitement of fever is by 
the use of emetic medicines, where, from peculiar circumstances, 
full vomiting may be indicated by the symptoms already men- 
tioned ; but in deciding upon their use we must take into view 
the previous state of the stomach, its present condition as to 



252 LECTURE XX. 

nausea, appetite, &c, the breath of the patient, and the foul- 
ness of the tongue. Where emetics can be safely administered, 
they are frequently given with great advantage, not only by 
removing particular symptoms, but by procuring a solution of 
the fever by their operation upon the whole system ; for their 
operation is to produce a general languor, and to act by the 
relaxation they produce in unlocking the secretions of the 
system in general. By these beneficial effects they are peculi- 
arly serviceable in typhus fever,* and especially in bilious 
remittents ; which last usually are accompanied with great de- 
rangement of the alimentary canal. On the contrary again, 
in yellow fever, in which there is always a tendency to an in- 
flamed condition of the stomach, as in gastritis, the practice of 
giving emetics is very generally a fatal practice, and I may 
say universally condemned by experienced physicians. Cau- 
tion, therefore, in the use of emetics, becomes necessary. We 
must accordingly know the peculiar character and cause of the 
disease in which we prescribe. We must not prescribe for 
mere symptoms. 

III. A third means of removing this excessive excitement in 
the second stage of fever is by cathartics. The following are 
the means to be employed for this purpose. 

1st. If the bowels have been hitherto neglected, do not wait 
for the relatively slow operation of cathartics, but immediately 
have recourse to an enema to evacuate the lower tract of the 
intestines. 

2d. Administer the purge composed of jalap, cream of tartar, 
aa gr. xv. ; calomel, gr. vi. M. This medicine is expeditious 
in its operation — produces large serous evacuations — and in a 
particular manner abstracts excitement from the brain and other 
vital organs. 

3d. The saline cathartics are among the best to be employed 
on account of their general effects upon the system ; i. e. by 
their operation upon the skin and the kidneys, as well as upon 
the bowels ; and many add to these a distinct sedative or re- 
frigerant effect upon the system, independently of their sensible 



* I mean typhus fever primarily so ; i. e. proceeding from contagion — pass- 
ing through a family : an emetic here is peculiarly proper, and will sometimes 
arrest its progress. 



TREATMENT OF FEVER. 253 

operation upon the excretions. The first of these is Glauber's 
salts, (the sulphate of soda,) called Glauber's salts from Rhudol- 
phus Glauber, a celebrated German chemist and practitioner. 
This is the most active of the saline cathartics, though the least 
acceptable to the stomach — gi. at a dose. 

2d. Rochelle salts, or sal de Seignette, as it was long called 
after the discoverer Mons. Seignette, an apothecary in Rochelle; 
it is the tartrite of potash and soda. It is more agreeable than 
the former, but less active — §i. or 3x. at a dose. 

3d. Phosphate of soda, or the tasteless purging salts — giss. 
It is much less active than the foregoing. 

4th. Sulphate of magnesia or Epsom salts, so called from their 
being obtained from the springs of the same name — also called 
the bitter purging salts, the sal catharticus amarus, and vitrio- 
lated magnesia. The teacher of the Materia Medica will doubt- 
less give you minute and ample details upon these subjects. 
The first is the most active but the most offensive ; the second 
less disagreeable, but less active ; the third, least offensive, but 
least active ; the fourth, though bitter, generally not offensive, 
and very active. These are best administered in Indian gruel, 
sweetened with brown sugar, si. of the salts to a pint of the 
gruel ; in chicken or veal soup ; in lemonade, or in simple wa- 
ter ; drinking thin gruel or chicken water during the operation. 
The gruel is the best, most laxative, and least exciting to the 
system, especially in fevers. 

IV. A fourth means of lessening the excitement attendant 
upon this stage of fever, is by the use of those remedies which 
operate upon the skin and kidneys ; the stomach and bowels 
having been previously attended to. First by 

1. Tartarized antimony, in small doses, sufficient to nause- 
ate the stomach to a certain degree ; for corresponding with 
this nausea of the stomach is the languor, deliquium or nausea, 
if it may be so called, of the whole system ; and indeed if nau- 
sea be not always manifested in the stomach, this languor 
shows itself in the diminished action of the heart and arteries, 
in the relaxed state of the exhalent vessels, so that the distant 
nerves and muscular fibres feel its effects, though the nerves of 
the stomach may be unconscious of its operation. That anti- 
monial medicines, particularly tartar emetic, have a peculiar 
operation on the skin, as Dr. Cullen supposed, independently of 



254 LECTURE XX. 

vomiting, or even nausea, is proved by the experiments of Wil- 
son, as related in his Essay on Gravel and Dyspepsia. See p. 
64, 125. 

There are various modes of exhibiting this medicine. It may 
be given in powder blended or embodied with loaf sugar ; say 
gr. ij. of the tartarized antimony ; 3ij. of loaf sugar, intimately 
mixed, and divided into eight doses, one every two hours; or 
dissolve two grains of the antimony in %iy of water, giving 
from one to two tea-spoonsful every two hours ; or gr. ij. to 
^viij. of water, giving half an ounce, i. e. a table-spoonful 
every two hours. It may be objected to this solution, that it 
undergoes a kind of decomposition ; at least that it loses its 
effect and becomes inert before the eight ounces are expended. 
To obviate this evil, give it in powder, or prepare a smaller 
quantity of the solution at a time. 

2. Antimonial wine is another form of exhibiting antimony; 
but this preparation is too uncertain, and therefore now gene- 
rally laid aside. 

3. James' powder — I mean the patent preparation : Bi. — di- 
vide in two or three parts, according to circumstances. 

4. Pulv. antimonialis, the oxyde of antimony with phosphate 
of lime, formerly antimonium calcareo phosphoratum. 

5. Pulv. antimonialis, with calomel — aa gr. i. every two 
hours, especially if the bowels be confined ; but if they have 
been well emptied, 

6. Sp. mindereri, the aq. acetatis ammonise, the acetate of 
ammonia, prepared with distilled vinegar, §ss. at a dose. Be 
cautious as to the mode in which the vinegar has been distilled, 
lest a portion of the leaden case of the still may be communi- 
cated to the vinegar, forming an acetate of lead. This pre- 
paration is rendered still more certain in its action upon the 
skin by the addition of laudanum ; say gtt. xxx. to giij. of the for- 
mer. M. Sometimes, too, advantage is obtained by combining 
with it from 3ij. to ^ss. of the sweet spirits of nitre to the giij, 
of sp. mind. Murray, in his Materia Medica, observes that the 
mindereri spirit is an inert medicine ! I want no other proof to 
show me that he was not a practical physician ; for a more 
efficacious medicine the Materia Medica can scarcely furnish. 
Dr. Caldwell, I perceive too, in his edition of Dr. Cullen, is not 
practically acquainted with this medicine, for he also considers 



TREATMENT OF FEVER. 255 

it as an inactive medicine. Dr. Duncan, as you will see in his 
Dispensatory, expresses himself in terms of high approbation 
of the operation of this medicine. We even see its injurious 
and depressing effects in typhus fever, when its use may have 
been too long continued, or it is made use of in a doubtful state 
of excitement. I mean doubtful, as it regards the use of ex- 
citing or depleting means ; for if wine be indicated, and the 
sp. mind, be given, great depression of the system soon shows 
itself in delirium, restlessness, &c. I have, in this way, often- 
times done mischief by its continuance ; but by thus knowing 
its injurious effects when improperly administered, I have been 
enabled to do more good with it where the state of the system 
calls for its use. 

7. Sal diureticus, acetate of potash, 3ij. saturated with 
vinegar, made into a draught, is particularly indicated to act 
upon the kidneys, when the secretion of urine is much diminish- 
ed, as well as the skin dry. 

8. Citrate of potash, 9i. of the carbonate to gss. of lime- 
juice — aq. font, giij — lavand. 3ij. to be given in cases in which 
the stomach is much disturbed, as in yellow fever, or by pre- 
vious excessive vomiting. This, though not so efficacious, like 
the sp. mind. I have also seen much abused by being persisted 
in, in the advanced state of typhus. 

9. Another useful diaphoretic is Glauber's salts, in small doses; 
viz. gi. divided into eight parts ; i. e. of 3ij. each. This was a 
favourite prescription of the late Dr. Kuhn, Professor of the 
Practice in the University of Pennsylvania. In some instances 
he combined with it two grains of tartarized antimony to the 
ounce, with the view of securing its effects upon the skin, or the 
superficies, as he denominated it. In all febrile diseases his at- 
tention was specially directed to the function performed by the 
skin. 

Among other favourite prescriptions of this most excellent 
physician, in the treatment of fever, and as a means of dimin- 
ishing the action of the blood-vessels, and of relaxing the su- 
perficies, was, 

10. The combination of the nitrate of potash with tartarized 
antimony, viz. 3ij. of the former, with two grains of the latter, 
divided into eight doses, one to be given every two hours. My 
intimacy with my fellow student and friend Dr. James, then 



256 LECTURE XX. 

the private pupil of Dr. Kuhn, and since the Professor of 
Obstetrics in the University of Pennsylvania, gave me an ample 
opportunity of witnessing the frequency of this prescription, as 
well as the former, in his practice. 

11. Another combination, much made use of by the late Dr. 
Bayley of this city, as well as by Dr. Post, was that of the 
super-tartrite of potash ; i. e. cream of tartar, 3ij. with two grs. 
of tart, antimony, intimately mixed, and divided into eight 
doses ; one every two hours. It is proper here to remark that 
this prescription, probably owing to the predominance of the 
acid, is somewhat uncertain in its operation. In some cases I 
have known it to prove very excessive in its effects. In one 
case it was administered in a pleurisy, after venesection, and 
a cathartic had been given : it produced a profuse evacuation 
by the bowels, and prostrated the patient before I could direct 
any thing to restrain the inordinate discharges it had occasioned. 

V. Among the means of diminishing the excitement of the 
system, is that of lessening the heat of the body by the direct 
application of cold, either in the form of cool air or cold 
water. The latter may be applied both internally and exter- 
nally ; for heat, as before observed, when excessive or accu- 
mulated in the system, becomes an additional stimulus, and an 
aggravating source of excitement and fever. 

To Sydenham we are much indebted for the -introduction of 
cool air into the chambers of the sick. To Dr. John Gregory ; 
to Dr. Haygarth, by his introduction and establishment of fever 
wards ; to Dr. De Haen of Vienna; to Dr. James Gregory, the 
late Professor of the Practice of Physic in the University of 
Edinburgh ; to the late Dr. Wm. Currie of Liverpool ; to Dr. 
Wright of Jamaica, and lately of Edinburgh ; to Dr. Robert 
Jackson, the author of the very valuable treatises on fevers, (for 
his works are valuable notwithstanding the fluctuation his mind 
had undergone on the subject of fevers,) — I say, to these writers 
the world is indebted for the introduction of cold water in the 
various external modes of its application in the treatment of 
fever. And I may add, that to many of the last mentioned phy- 
sicians, Dr. Currie especially, we are to ascribe the revival of 
the ancient practice of administering cold water, and other 
cool drinks, during the hot stage of fever, as well as its appli- 
cation to the surface. I mean the practice which you will 



TREATMENT OF FEVER. 257 

find recorded in the writings of Galen, of Avicenna, of Rhazes, 
of Aetius, and of Celsus. 

Galen considered cold water a most important remedy in 
fever ; so did Avicenna, Rhazes, and other Arabian physicians. 
Aetius advised total abstinence from liquids at first, until the 
thirst was augmented; then he allowed the most free indul- 
gence in cold drink. Celsus followed him, by allowing the most 
copious draughts of cold water in the height of the fever — but 
not until great heat and thirst called for it. Lib. iii. cap. 7. Af- 
terwards, until the cold regimen was introduced by Sydenham, 
the alexiphermic or heating system prevailed, by which the 
patient was suffocated by heat, by hot drinks, and loads of 
clothing — scarcely exceeded by the suffocating vapour-baths 
of the itinerants now travelling through our state, to the 
great destruction of those who are exposed to their frauds and 
their quackery. 

Extremes are to be avoided — the indiscriminate use of 
cold applications, as well as the means of accumulating and 
increasing the heat of the patient. We are to recollect 
that the skin performs the important office of conveying 
out of the body two sources of irritation or excitement ; 
namely, the saline materials which compose the perspirable 
fluid, and caloric. I might add three, for the quantity of 
fluid evacuated by the skin is another means of diminishing 
excitement, as far as the volume or quantity of fluids may 
be the cause of fever, or may have agency in the continuance 
of it ; but the two former, viz. the saline matter and caloric, 
have manifest influence when retained, in augmenting febrile 
action ; for to remove heat, without attention to the other mat- 
ters discharged by the surface, is not sufficient^ if we wish to 
remove or to guard against all the sources or consequences of 
febrile excitement. Cold washing and cold drinks may dimi- 
nish temperature alone, but they are not calculated to continue 
the discharge by the skin, which is to remove the noxious ma- 
terials we ordinarily pass off through that extensive outlet to 
our system. Dr. Currie even has been too inattentive to the 
nature of this function, and the chemical properties of the mat- 
ter evacuated — ascribing too much to mere temperature, and 
neglecting the materials which are conveyed out of the body 
23 



258 LECTURE XX. 

by this discharge. Examine and inquire for yourselves. Attend 
to this subject in all its relations to the present state of chemi- 
cal science. Here, too, is presented to you an excellent theme 
for an inaugural exercise. The qualities of the materials pass- 
ing off by the skin, and their effects when retarded or obstructed 
in producing febrile action and a vitiation of the system ; or an- 
other subject, the use and abuse of cold water in fevers. 

When, then, at what stage of fever — under. what circum- 
stances, are cold water and cold drinks to be employed? I an- 
swer, during great heat and excitement of the body, when the 
skin is dry and flushed ; and then they are to be employed 
merely for the purpose of abstracting the superabundant heat 
or caloric, which, by the excitement or irritation of the exha- 
lents, prevents the discharge of the perspirable matter. Ac- 
cordingly, perspiration flows after the use of cold applications 
and drinks. But if they be afterwards continued, that very 
discharge is restrained which they have been the means of 
effecting. Tepid drinks, not cold, are then to be administered, 
and cold applications should be suspended while such discharges 
from the surface may be continued, for no more effectual means 
of diminishing temperature can be employed than the discharge 
of the perspirable fluid from the surface. 

Dr. Currie's remarks on this subject deserve your attention. 
" The safest and most advantageous time for using the asper- 
sion or affusion of cold water; i. e. at the temperature between 
87° and 75° of Fah. is when the exacerbation is at its height, viz. 
from 6 to 9 P. M. But," he adds, " it may be safely used at any 
time, when there is no sense of chilliness present, when the heat 
of the surface is above what is natural, and when there is no 
general or profuse sensible perspiration." He also prohibits 
the use of it in cases of diarrhoea or dysentery. In that re- 
spect, Dr. Thomas has certainly erred, by the prescription of 
cold drinks and cold applications in diseases of that descrip- 
tion, not adverting to the injury they produce in all diseases 
attended with local inflammation. 

How is cold most advantageously applied ? By cold affu- 
sion 1 By cold washing 1 I answer, by a better mode, by 
means of a sponge, which, successively applied, reduces the 
temperature several degrees lower than simple allusion. The 
relative advantages attendant upon this mode of applying cold 



TREATMENT OF FEVER. 259 

water were well ascertained by Dr. Gregory in the Infirmary 
of Edinburgh, and by Dr. Currie of Liverpool, in the numerous 
cases of typhus that those cities presented, especially among 
the poor resorting to their public hospitals. The same results 
were exhibited, not only in the private practice of Dr. Bard 
and myself, in the treatment of yellow fever, but also in nume- 
rous cases of that disease, as they appeared in the New York 
Hospital. 

In my own case, when attacked with that disease in 1708, 
I had recourse to the same practice, of washing my limbs with 
cold vinegar and water by means of a napkin, repeatedly ap- 
plied in succession to the different parts of my person ; at the 
same time making use of cool water as my drink. Very ge- 
nerally it was succeeded by a profuse perspiration, which was 
afterwards continued by tepid, not hot drinks — such as toast 
water, common tea, or a cup of balm or catmint. It may in 
this place be remarked, that the external application of tepid 
water, i. e. warm, not hot, say from 87° to 97° of Fah., also 
reduces the temperature of the body, especially when the sweat 
is flowing and the temperature exceeding 97i°,the natural degree 
of heat. Indeed it appears to me, that it more effectually carries 
off the superabundant caloric than cold water, as it is more 
readily converted into vapour, by which the body is left rela- 
tively cool ; and that without the check of the perspiration 
produced by cool or cold applications. 

Dr. Currie admits, that " in many cases the heat of the body 
is lowered as speedily by the affusion of tepid water as by the 
affusion of water that is cold." He adds, if I mistake not, in 
some cases the heat is lowered more speedily by the tepid 
water ; i. e. the evaporation from the surface is more copious 
from the tepid affusion, and on this the cooling of the body 
very much depends. But this is not all : the tepid affusion 
is little, if at all, stimulating, and does not, like the cold affu- 
sion, rouse the system to those actions by which heat is evolved, 
and the effects of external cold resisted. He concludes, " it very 
generally produces a considerable diminution of heat, a dimi- 
nished frequency of pulse and respiration, and a tendency to 
repose and sleep." 

Cold drinks, it may be added, are productive of great irri- 
tation or excitement, given while the perspiration is flowing. 



260 LECTURE XX. 

Tepid lemonade, teas moderately stimulating, especially in those 
fevers where the stomach is irritable, as in the yellow fever, 
should now be prescribed. The nepeta cataria, the sage, (sal- 
via officinalis,) snakeroot, (aristolochia serpentaria,) and the 
boneset, (eupatorium perfoliatum,) maybe now advantageously 
directed, as well calculated to preserve the perspirable state of 
the surface. They are accordingly among the most valuable 
of our domestic remedies in fevers. Many families place an 
exclusive reliance upon those natural febrifuges of our country, 
and rarely resort to the physician. In the present state of the 
practice of medicine, in which the physician places his reliance 
upon mercury, I believe they are right. This is certainly con- 
firmed, as it regards the yellow fever. Richardson Underhill 
of New York, and John Vaughan in Philadelphia, certainly 
were more successful in the treatment of that disease than the 
greater part of the graduated doctors of those cities. 

I have already mentioned the virtues of the sage, and the 
celebrity it possessed in former days. Cur moriatur homo cui 
salvia crescit in horto? was proverbially said of this plant. 
The snakeroot became no less esteemed for its febrifuge virtues. 
The eupatorium perfoliatum, or boneset, now enjoys equal 
reputation with either of the plants mentioned, and to that 
it is justly entitled. Indeed, I consider it as superior to either 
of them in its sensible effects upon the functions of the system. 
The infusion of this plant, when given warm and of consider- 
able strength, possesses active emetic qualities. It also acts 
upon the bowels as a cathartic, at the same time that it ope- 
rates upon the surface as a powerful sudorific ; afterwards 
(riven in the form of the cold infusion, like the bark and other 
bitters, it is a valuable tonic. It is generally remarked, that 
every climate and country furnishes its specific against the dis- 
eases of that country. In this plant it is peculiarly true that it 
possesses all those medicinal qualities which constitute it an 
antidote to the fevers of this climate ; exhibiting all those me- 
dicinal operations upon the system that are obtained from the 
James' powders.* 

* See Dr. Anderson's Inaugural Dissertation on the Eupat. Perfol. His expe- 
riments upon its medicinal operation, and his chemical analysis of it, form a 
model deserving- your imitation, in preparing a dissertation upon any similar sub- 
ject. 



TREATMENT OF FEVER. 261 

What is to be the food of the patient in this stage of fever? 
I answer, bread and water, or a diet very little departing from 
this simple fare — a dish of tea with a piece of bread, dry 
toast, or a biscuit ; a cup of gruel ; some stewed or roasted 
apples, or peaches ; or at most, a little boiled rice or barley, is 
to be occasionally allowed : for the strictest abstinence should 
be enjoined in this state of increased excitement. And unless 
the physician gives particular attention to the diet of the sick, 
directing both what the patient is to eat and drink, and what 
he is not to eat or drink, proscribing as well as prescribing, he 
will find that the kindness of the nurse, or too kind friends 
and attendants, will, by their panadas, their calves' feet jelly, 
their meat soup or beef tea, their custards, or other good things, 
soon bring about a renewal of fever, and thus counteract all 
the benefits which may have been otherwise obtained from 
his advice. Another very important direction to be given in 
fever, especially if typhus fever be apprehended, either from the 
original cause of the diease or from the long continuance of it, 
is to confine your patient at this time to vegetable nourishment, 
avoiding animal food altogether, even in the shape of soups, so 
frequently but improperly given in fevers and febrile diseases. 
Animal food, at this period or stage of fever, in this high state 
of the excitement of the system, is too stimulant at all events, 
independently of its greater tendency to the putrefactive fer- 
mentation, and the vitiation of the system to which it gives 
rise, and to which the body at this time is peculiarly predis- 
posed. No less attention should be given to the regimen of the 
patient than to his diet. Your attention should be directed, 
first, to the air of the room, both as it regards its quality and its 
temperature. Upon being called to a patient in fever, and it 
is likely to be of any duration, especially if of the typhoid cha- 
racter, and particularly if it occur in the warm seasons of the 
year, endeavour to place him in an apartment which is suffi- 
ciently large, and which you can at pleasure ventilate. If possi- 
ble, too, obtain for him a room with a fire-place ; the circulation 
of air which this secures is of great importance to the sick. 
Another good rule is, to place the bed at a little distance from 
the wall, that the patient may avoid the current that takes 
place upon the sides of the room. Avoid also the lodgments of 
air that are apt to take place in the corners of the room, by 
23* 



262 LECTURE XX. 

placing the sick nearer the centre of the apartment. With 
regard to temperature, it should not exceed 60° or at most 65° 
of Fahrenheit, pineapple heat. Preserve your patient, too, 
from all exercise, both of body and mind, as far as possible. 
Attend likewise to his clothing, that it be of a proper sort, and 
frequently changed. Remember flannel or cotton worn next 
the skin in this climate, as I have before remarked, is prefer- 
able to linen, especially in fevers. But frequent changes are 
indispensably necessary. Look too to the bed and bedding of 
your patient. In winter, a feather bed is allowable, and really 
more comfortable, and in most cases is really more beneficial 
to the sick ; but in summer the mattress is to be preferred, as 
less heating to the body. The curtains of the bed should be 
totally removed in summer, and in winter they should be fre- 
quently thrown aside, for the purpose of admitting fresh air to 
the person of the patient. In summer, the bedding should be 
light, consisting of a sheet and a single blanket, and these should 
be frequently changed ; a less quantity, even in the summer 
season, would not be sufficient to secure the perspiration which 
is necessary in the treatment of all fevers. But in winter, an 
additional blanket or coverlet will be called for. But I beg 
you to guard against the common error committed in the sick 
room, that of loading the patient with bedclothes ; for the very 
accumulation of heat becomes of itself a sufficient stimulus to 
renew the fever that may have just terminated. 



263 



LECTURE XXI. 



THE GENERAL TREATMENT OF FEVER.— TREATMENT OF THE 
THIRD STAGE. 



We now proceed to the third stage, usually denominated 
the sweating stage of fever. This has been induced either 
spontaneously, or by the means that were employed for the 
purpose of diminishing the excitement which has constituted 
the two preceding stages. In either case, a question occurs — 
Is the second stage completely terminated 1 Has a perfect 
apyrexia or absence of fever been induced ? Or does the fe- 
brile excitement still continue ? 

If the patient be free from fever, his pulse is generally re- 
duced to its natural frequency and softness ; his respiration has 
become natural; his skin is moist and of its ordinary tempera- 
ture ; his tongue moist and becoming clean, with a plentiful 
■ secretion, particularly from its edges. I speak of apyrexia 
after simple excitement, not in the compound or complicated 
excitement of typhus fever, in which case, though the fever be 
ended, the tongue may still be foul, and even the arterial sys- 
tem manifest some irregularity. The urine is thick, high co- 
loured, and deposits a brick-dust sediment ; his feelings and 
state of mind are again recovered, except that he is sensible of 
more or less debility and languor. If the sweating be now 
continued, a still greater expenditure of the patient's strength 
takes place ; his extremities become cold by the evaporation 
produced, and if he be of a slender habit of body, or he is 
debilitated by age, his prostration may be such that his life 
may be in danger. It becomes necessary, then, to restrain the 
discharge by the skin. How is this to be effected ? 



264 LECTURE XXI. 

1st. By change of his dress, and the admission of air to the 
surface of his body ; by changing his bed and bedding, and by 
diminishing the quantity of his bedclothing. 

2d. By the administration of stimulant food and drinks, and 
especially by cool drinks. A cup of tapioca, the fecula obtained 
from the jatropha manihot ; of arrow root, obtained from the 
maranta arundinacea ; of sago, from the cycas revoluta, or 
circinalis ; of salep, the produce of the roots of the orchis 
mascula, or the orchis morio ; of panada, prepared from wheat 
Bread and water, boiled ; of caudle, made by boiling oatmeal, 
or common cornmeal, or Indian meal gruel. Either of these, 
with the addition of wine, sugar, and the spice of nutmeg, 
(myristica moschata) or cinnamon, (laurus cinnamomum) 
may now be advantageously administered to the sick. Or a 
wine toast, with the before mentioned additions, may be given 
him ; or a cup of porter and water, with a small quantity of 
nutmeg added to it, and gratefully sweetened, will be pecu- 
liarly useful and agreeable to the sick. Vegetable nourish- 
ments, too, it should be recollected, are preferable, if you have 
reason to suspect either a continuance or renewal of the fever, 
or a typhoid tendency likely to supervene. But even if a per- 
fect apyrexia has been induced, animal food should be cau- 
tiously made use of, even in the form of soups. And when 
soups are given, they should be made of the less stimulant 
meats, as chicken or veal, and then prepared with a variety of 
vegetables, such as celery, (the apium graveolens,) parsley, 
(the apium petroselinum,) an onion, (allium cepa,) turnips, 
(brassica rapa,) carrots, (the daucus carota,) barley, (hordeum 
distichon,) rice, (the oryza sativa,) &c. 

But if the stomach has been much debilitated and disturbed 
with flatulence and indigestion, and the patient be much re- 
duced in strength, and the apyrexia is so perfect that there is 
no reason to apprehend a return of fever, then a small quan- 
tity of animal food, broiled or roasted, may be made use of, 
especially a broiled bird. And it may be rendered more stimu- 
lating by the usual condiments, such as salt, pepper, and mus- 
tard, or a cup of brandy, or spirits and water. In that case, 
soups and vegetable nourishments, especially the more acescent 
vegetables, should be avoided, as in a weak stomach they 
readily run into fermentation. Some medicines, too, are to be 



TREATMENT OF FEVER. 265 

administered, to prevent the recurrence of the paroxysm, and 
to build up the system. These will be hereafter noticed. 

But it is very possible that the sweating stage, which has 
been induced, has only afforded the patient a very partial re- 
lief — a mere remission or abatement of his symptoms. His 
heat is still continued, though his skin be moist; his pulse is 
still more frequent than natural, or if not more frequent, it is 
still manifesting a degree of hardness and irritation in it, per- 
haps both. But recollect, that the frequent pulse may exist 
without fever, as we see in the debilitated habit of body, from 
whatever cause ; but we see this frequency, especially in the 
debility attendant on convalescence, and in persons of a sus- 
ceptible state of nervous system. His respiration, too, is in 
proportion frequent ; his excretions by the skin and the kidneys 
are less copious than they should be ; some stricture on the ex- 
treme vessels yet remains : — there is still some irritating cause 
operating upon the system. This source of irritation may be 
in the intestinal canal, or it may be in the blood-vessels ; i. e. 
in the condition of the fluids of the system. In the first place, 
it may have arisen from miasma, which is still operating 
upon the body, which, perhaps, has been long exposed to its 
action, and thence has become saturated with such miasma. 
This is frequently the case, when it is the cause of remitting, 
as well as intermitting fevers, especially in the autumn, in a 
warm climate, and after a hot summer. 

2dly. The fever may have been generated in the system, and 
have derived its origin from a colluvies in the bowels, which 
is not unfrequently the case in hot climates, and in the summer 
and autumn of temperate climates. Bilious remittents, with a 
typhoid tendency, are thus frequently engendered, independently 
of external causes. This type of fever may have been gene- 
rated in the system by causes not confined to the bowels, viz. 
by a scorbutic habit of body ; the effects of a bad diet, want 
of fresh vegetables, by bad air, living in foul and confined 
apartments. But whatever may have been the exciting cause 
of the fever so induced, such fever has at least a great ten- 
dency to assume the typhoid character, in consequence of the 
circumstances just mentioned. Jail, typhus fever, and dysen- 
tery, are oftentimes thus induced ; or, 

3dly. The fever now existing, may be the effect of conta- 



2(36 LECTURE XXI. 

gion, a " materies ah extra," introduced into the system. It 
may be small-pox, measles, chicken-pox, scarlet fever, plague, 
yellow fever, the various forms of typhus fever, spotted fever, 
remitting fever. In these cases, the continuance of fever is to 
be looked for. While the excitement continues, but is unaccom- 
panied by symptoms of putrescency, continue the use of the 
remedies which have been already recommended, especially 
those necessary to keep the bowels open, and to preserve a 
continuance of the excretions by the skin and kidneys. For 
this purpose, enemata should be daily administered, together 
with the internal use of cathartic and sudorific medicines, as 
combinations of antimony and saline medicines, as Dr. Kuhn's 
prescription. If the action of the vessels be kept up, tepid 
washing should also be frequently renewed. Should it prove 
an eruptive fever, the excitement must soon produce an erup- 
tion on the surface of the body, or the poison must soon wear 
itself out, or perhaps be eliminated from the body altogether, 
by persisting in your attention to the excretions. But if other- 
wise, and you have reason to believe it a remitting form of 
fever, or of a typhus tendency, pay constant and daily atten- 
tion both to the bowels and skin, as among the best means of 
counteracting a vitiated state of the fluids, and of terminating 
the fever. And if it be a fever from contagion, it will pass 
through its ordinary course, with less injury to the system, 
while these discharges from the bowels and surface are pre- 
served, and the excitement of the system, if I may so express 
it, is divided among the functions of the body. But in a case 
of continued fever, properly so called, if these functions are all 
attended to, and prove insufficient to effect a complete solution 
of the fever, lose no time, but proceed upon the principle of 
converting a general into a local irritation, by the free and 
repeated application of blisters — for blisters are now espe- 
cially serviceable. The system is yet very sensible to the im- 
pression they produce upon it, and there is less danger now 
to be apprehended, either from the debility occasioned by the 
discharge they produce, or the exhaustion of the tone of the 
parts themselves to which they are applied, than at the more 
advanced stage of the disease — for in the latter stage they 
are oftentimes attended with dangerous consequences, both 
to the whole system and to the parts of the body to which 



TREATMENT OF FEVER. 267 

they are applied, by inducing sphacelus. But in the present 
stage they are frequently serviceable, by producing a con- 
centration of all the irritations of the system upon the parts 
now acted upon, analogous to the critical eruptions in fevers, 
or to the effects of salivation or other critical discharges, 
as excessive sweating, diarrhoea, urine, or sometimes by 
hemorrhage. The inflammation of blisters is no less critical 
and serviceable in many instances. But do not postpone 
their application, as was formerly too much the case with 
practitioners. Hence the old prejudices, and which are still 
occasionally met with in the sick room, that the case is a hope- 
less one when blisters are made use of. In the last stage of 
fever, it is well known, that they are rarely employed with 
benefit, except for the relief of particular symptoms ; as for 
coma, in the advanced stage of typhus, in irritation of the 
stomach, in yellow fever, oppressed lungs from congestion, in 
peripneumony, in the inflammation of the intestines in dysen- 
tery, or of the peritoneum in puerperal fever. Some physi- 
cians, indeed, reprobate the use of blisters in all stages of the 
typhoid form of fever. Dr. Moore never thought them useful 
in fevers of this character. See his Sketches, p. 531. I 
confess, I never saw them do much good in the more ad- 
vanced stage of typhus fever ; but in the early period, they 
are among the best means of arresting general fever, and of 
directing its violence to the local irritation produced. For 
this purpose, then, when you have failed by the remedies al- 
ready enumerated, have recourse to blisters. Apply them 
successively to the wrists, to the ankles, behind the ears, be- 
tween the shoulders, to the chest, to the pit of the stomach, or 
to the hypogastric region, according as the head, the lungs, 
the stomach, the intestines, the bladder, or the uterus, may be 
more peculiarly affected than other parts of the system. But 
if the fever be general, without such local tendencies, apply 
first a pair of blisters to the forearms, and when you may 
have obtained their full effects, and the fever is still continued, 
(allowing a reasonable time for the excitement produced by the 
blisters themselves, say three or four hours, to subside,) apply 
another pair to the ankles, or to the inside of the thighs.* 

* Riverius, speaking of malignant fevers, and of the advantages derived from 
blisters, observes : — " Ubi maxima est malignitas, unicum vesicatorium non 



268 



LECTURE XXI. 



Blisters in an adult, under ordinary circumstances, in order to 
produce their full effects, should be applied, eight, ten, or twelve 
hours ; not so in the more advanced state of fever, or in chil- 
dren. In this state of fever, in the case of an adult, six or 
eight hours, and to children from two to four hours, will give 
you all the local excitement and inflammation you will wish 
to be produced by them. Do not wait for the elevation of the 
cuticle, for upon the first dressing afterwards, you will find 
that an effusion of serum will have taken place. You must be 
precise in your directions on this subject, or they will be too 
long continued. In cases of sphacelus of the parts, as in the 
ulcers from burns, or where blisters have been applied, yeast 
poultices are frequently applied ; but the best application I have 
found is an ointment composed of the acetate of copper and ce- 
rate, or hogs' lard, from three or four to ten grains to the ounce. 

If by these means you do not succeed in obtaining a crisis 
in the fever, you have now reason to look for a different 
state of things. You have grounds to anticipate a secondary 
fever ; or that stage of fever which arises from the deranged 
state of the fluids, now appears. For the fever being continued, 
mere action alone, long-continued, will produce such a de- 
rangement of the whole system, and of the excretions, that 
typhus, in other words, a vitiation of the fluids, constituting 
their putrescent tendency, is inevitably the consequence of such 
continuance of febrile excitement. 

The system now being more debilitated, and consequently 
more irritable ; the state of the fluids, too, being changed, be- 
come a greater source of irritation to the heart and arteries. 
Hence, then, the pulse becomes more frequent, small, and 
irregular. For the heart and arteries, like the other parts of 
the system, become morbidly sensitive, even to ordinary im- 
pressions ; but much more so to any new impressions that may 
be made upon them. Now fear, any sudden impulse of mind, 
or agitation of the body, even the muscular exertion of getting 
in or out of bed, or of changing his clothes, will affect the 
patient. Every new object that comes before him excites his 

sufficit, sed plura admovenda sunt ; soleo ego in magna morbi ssevitia, quinque 
locis admovere, cervici nimirum, utrique brachio, parti interiori inter cubitum 
et humerum, et utrique femori, parti etiam inferiori inter inguina et genua, 
cum feliei suecessu." Riverii Opera, p. 541. 



TREATMENT OF FEVER. 269 

vessels to more frequent action — light, noise, conversation, all 
act upon him. Every evacuation from the bowels now adds 
to his irritability, which shows itself no less in the blood-vessels 
than the other parts of his system. An obstruction of the 
bowels, the retention of urine, even the continuance in one 
posture, affect him in this respect very sensibly. The respira- 
tion, too, becomes hurried and irregular. The heat now shows 
that peculiar biting quality that we have before mentioned. 
The skin, too, becomes dry. The brain is also more or less 
disturbed, showing itself in the mind and body, or sometimes 
appearing in the form of stupor. This is a common occurrence. 
Hence the origin of the term typhus, which signifies stupor. 
It is also traced to the verb t«<?>», to inflame, denoting perhaps 
the extraordinary heat of this form of disease ; or it may be 
referred to the inflammatory stage that frequently precedes it. 
His eyes become insensible to light — they remain half closed. 
His senses, indeed, are variously disturbed, sometimes exces- 
sively alive to impressions ; at other times he is totally insen- 
sible — sight, hearing, taste, smell, feeling, are all morbidly 
affected ; indeed, all these senses are in a state of paralysis. 
Great restlessness, perhaps coma, succeeds. Subsultus tendi- 
num and delirium follow — even his sleep is disturbed by dreams. 
This determination is more especially troublesome at night, but 
not so early in the day. Involuntary discharges, too, take place 
by urine and faeces. These, too, become more offensive, as well 
as his breath, and the other discharges. The cause of this con- 
tinued irritation is now referrible to the first exciting cause, as 
miasma or contagion ; to the condition of the fluids, induced by 
the retention of the natural excretions; by the absorption of the 
vitiated secretions and excretions; and, possibly, by some change 
which may have been wrought by the vascular system itself upon 
the fluids. If the vessel operates upon its contents in the process 
of secretion, it certainly may also act upon the circulating 
fluids. Indeed, we have the evidence of some such action in 
the changes effected in the lacteals, and in the process of san- 
guification. The effects of climate and season are also to be 
taken into consideration, in accounting for the obstinacy and 
the duration of the fever, and the changes now taking place 
in the system. Another possible source of such vitiation is, 
perhaps, to be found in the atmosphere to which the patient 
24 



270 LECTURE XXI. 

may have been exposed, as in prison, on board ship, in a 
crowded hospital, or in a garrison. 

Puerperal fever at Aberdeen, and at Edinburgh, is thus ren- 
dered typhoid in the lying-in wards of the infirmary, owing to 
the presence of typhus fever, which gives that type or charac- 
ter to every inflammatory disease, especially puerperal fever. 
Hence the difference of opinion among writers, relative to the 
inflammatory or the typhoid character of that disease ; some 
contending for its exclusive inflammatory type, others that it is 
always of a putrid tendency. Even the want of cleanliness 
in some private families, gives a malignancy to a disease that 
is not otherwise of that character. Dysentery, by such neglect 
of personal cleanliness, is thus rendered contagious, even in 
the otherwise pure air of the country. The confinement of the 
sick to small and unventilated apartments, or want of personal 
cleanliness in the individual, will furnish a solution of the phe- 
nomena which are now exhibited in the typhoid state of fever. 
What, then, are the means of arresting its progress, and of 
counteracting this condition of the system 1 These will be the 
subjects of the ensuing discourse. 



271 



LECTURE XXII 



TREATMENT OF THE TYPHOID STATE OF FEVER 



The treatment of the typhoid state of fever now falls under 
our notice. 

Dr. Sims remarks : 'I shall ever fear a physician is in fault 
if a person dies of a fever, to whom he has been called whilst 
any degree of strength remained, and the patient could be 
obedient to his directions."* But notwithstanding this obser- 
vation of Dr. Sims, there is no situation where the judgment, 
the skill, and the attention of the physician are in greater 
demand than on this occasion. There is no stage of fever 
more embarrassing for the young practitioner, than that which 
is now to be considered. But I hope to give you some facts 
on this subject that will prove useful to you at the bedside of 
the sick. I very early found them so to myself, and have 
since had good reason to be confirmed in their correctness. 

How is this typhoid state of body to be counteracted ? — In 
what does it consist? You will remember it consists — 1st. 
Of debility, the effect of the long-continued preceding excite- 
ment ; and consequently, as the attendant upon that debility, 
an increased susceptibility to impressions. 2d. In a certain 
degree it is constituted by a putrescent state of the system ; 
for both of these conditions of body exist at the same time. 
The indications then corresponding with this state of the solids 
and fluids are likewise two-fold. 

I. To counteract the debility which keeps up the irritable or 
excitable state of the system. 

* Sims' Observations on Epidemical Diseases, &c. p. 87. 



272 LECTURE XXII. 

In this disease, as before remarked, the heart and arteries are 
more susceptible to impressions, owing to the debility of the 
system. Hence it appears, that the least bodily exertion of the 
patient, or the least mental irritation, excites his heart and ves- 
sels to more frequent action. Under these circumstances, the 
hasty observer prescribes the means of depletion, and those 
narcotic and other medicines usually denominated sedative, as 
for a disease of supposed simple excitement. But this sensi- 
bility of nerve, this hurried circulation and quickened respira- 
tion connected with it, (for it shows itself in the heart and 
vessels no less than the other parts of the system,) are only to 
be removed by stimulants, both diffusible and permanent: they 
only can counteract this state of the system. This is to be 
done, not by a continuation of depleting or evacuant medicines; 
not by the sedative effects of opium, camphor, digitalis, and 
other remedies of this nature, so generally resorted to in con- 
sequence of the stimulant operation which these narcotics are 
supposed to possess. Opium, administered as it is ordinarily 
given in typhus fever, like foxglove in dropsy and consump- 
tion, proves indeed an anodyne to your patient, for it is the 
passport to the grave. At least, such has been my observa- 
tion of its effects ; but examine for yourselves. Even opium 
and wine combined, and which are so frequently employed, are 
of doubtful effect ; it may however happen that the wine by its 
stimulant operation, if given in large quantities, may be suffi- 
cient to counteract the sedative operation of opium. Nor will 
camphor be found more useful ; on the contrary it is equally 
debilitating with opium. Its sedative and deleterious effects 
on the whole system are well ascertained. I have therefore 
proscribed them both from my practice in the advanced state 
of fever, with the exception of administering opium as an occa- 
sional anodyne, or for the purpose of restraining diarrhoea ; 
but the repeated doses of it which some physicians are in the 
habit of prescribing, on account of its supposed stimulant 
effects in preserving the tone of the system, cannot in my 
opinion be too severely reprobated. Nor is this febrile excite- 
ment to be removed by persisting in the use of mercury, so 
frequently and so indiscriminately prescribed in this state of 
body. Small doses of calomel and antimony may be advan- 
tageously administered as alteratives before great prostration 



TREATMENT OF FEVER. 273 

has taken place, and especially when the bowels are confined : 
but if they afterwards be continued, they should be given in 
conjunction with small doses of opium to secure their opera- 
tion upon the surface, and to prevent their effects upon the 
bowels. But if you depend upon the mercury's salivating the 
patient at this period of the disease, you will be frequently dis- 
appointed. The evacuations it occasions from the bowels will 
alone frequently run off the strength of the patient ; and even 
where salivation takes place, I have known the fever, neverthe- 
less, to prove fatal. The late Dr. Laurence fell a victim to 
the fever of 1798, notwithstanding a salivation was obtained. 
In some instances, too, it has happened that although salivation 
has been effected, the patient has sunk under diarrhoea, which 
has succeeded to this use of mercury. But it must be acknow- 
ledged that it is a very rare occurrence, that the patient has not 
recovered where salivation was induced ; but in nine times out 
of ten, nay nineteen out of twenty, you will fail to induce a sali- 
vation in this state of the system, in which case the remedy pro- 
duces irreparable injury. The debility then of the solids is 
only to be safely counteracted by the free use of stimulants, 
including both the diffusible and those permanent stimulants 
called tonics. The diffusible stimuli advisable in this state of 
things, are the vol. alkali and aether. In case of stupor or 
coma frequently attendant on the typhoid type, and in the 
typhoid state of peripneumony, the vol. alkali is particularly 
indicated. I had a case of the former in the state prison, where 
the pressure on the brain was such as to reduce the pulse to 
twenty and thirty strokes, and in all other respects the symp- 
toms of this state of fever existed in an alarming degree. In 
this case, the vol. alkali was followed by the most decidedly 
good effects. In like manner, in every obstinate case of perip- 
neumony, the most beneficial effects were obtained from the 
use of this medicine. In the typhoid form of that disease, this 
medicine may be given in various forms ; it may be given in 
bolus of v. gr. or vi. gr. of the carbonate of ammonia made 
up with the conserve of roses ; or dissolve 3i. in gvi. of mint 
water, and add gss. of lavender to the mixture — ^ss. to be given 
every two hours ; or it may be administered in the form of 
aq. ammon. xv. gtt. or xx. gtt. every two or three hours in the 
drinks of the patient, or in sweetened water. Or it may be 
24* 



274 LECTURE XXII. 

prescribed in the sp. ammon. or the sp. amnion, aromat., which 
is the most elegant form of giving that medicine, and is most 
grateful for internal use. 

iEther, either the sulphuric, or that form of it called the 
anodyne liquor of Hoffman, may also be given in the typhoid 
state of fever, especially for the removal of delirium and sub- 
sultus tendinum, with the best effects — from twenty to sixty drops 
of this liquid should be frequently administered, say every two 
or three hours, in a little sweetened water. From its temporary 
effects in this agitated state of the system, it is called the ano- 
dyne liquor. The lavender compound is another valuable sti- 
mulus to be administered under such depression of the vital 
powers as above, and aether may also be combined. But we 
must not rely upon the diffusive stimulants alone. Tonics are 
also to be given in this prostration of the system. Bitters, in 
the form of the infusum amarum, prepared with water, or the 
tinctura amara, (i. e. tinct. gentianse composita, consisting of 
gentian root, orange peel, canella alba or cardamom, seeds,) 
rendered more grateful by the addition of a small quantity of 
the sp. lavand., should now be given. This last form, with 
children, and in persons of a very delicate state of the stomach, 
is that preferred ; but under other circumstances you will find 
the following formula to embrace all the advantages to be ex- 
pected from bitters. You will recollect the propensity to fer- 
mentation in the stomach, when thus debilitated, and you will 
also keep in mind the necessity of regular evacuations from the 
bowels. The formula referred to combines all the means ne- 
cessary for the purpose of controlling such fermentation when 
excessive, and of preserving the peristaltic motion of the intes- 
tines. The formula is as follows : quassia-wood, columbo root, 
aa. 3ij. ; cort. aurant. 3i. ; rhubarb root bruised, from 9 to 3ss. ; 
carbonate of potass., or soda, from 9 to 3ss. ; water, §xx. ; boil 
to gxvi. and strain; and to make it more acceptable, add 3n\ 
or iij. sp. lavand. Of this mixture, when cold, let the patient 
take a wine-glassful every two hours. In summer add gij. of 
tinct. amar. to the mixture, to preserve it. You perceive I com- 
bine different bitters in the same prescription. It is believed by 
most practitioners, that the combination of two or more of the 
bitters is more useful than any one alone, and is more grateful 
to the stomach. That remark was originally made by Syden- 



TREATMENT OF FEVER. 275 

ham ; it has since been confirmed in the practice of the expe- 
rienced Fordyce ; and the observation is repeated by Dr. Clarke, 
in his Observations on the Diseases of Females, p. 98. " Bitter 
medicines," says Dr. Fordyce, " which tend to strengthen the 
system, as far as my experience has gone, sit easier on the sto- 
mach, and tend more to strengthen the system, when mixed 
together, than when any one of them is employed singly." See 
paper by Fordyce, 2d vol. of the Trans, of the Soc. for Med. 
and Chir. Knowledge. 

Another compound, very useful under similar circumstances, 
is an infusion of chamomile flowers or orange peel, and the Vir- 
ginia snakeroot — an advantage in which is, that it has a con- 
siderable operation upon the surface of the body, and to which 
the antiseptic qualities of the snakeroot in particular are usu- 
ally ascribed; 3ij. of the chamomile and snakeroot, with Si. of 
orange-peel, are sufficient to make a pint of tea — of this cold, 
a wine-glassful should be taken frequently. Valerian, in some 
cases, is a useful addition. 

The Peruvian bark is also frequently had recourse to by 
practitioners, in typhus fever. For the most part, however, 
except in the more advanced state of typhus fever, it is too 
astringent, unless when combined with snakeroot in decoction. 
In this form, it may be advantageously prescribed in many 
stages of typhus fever, when such state is clearly marked. The 
bark in substance is also frequently administered ; but it very 
frequently proves too irritating to the stomach and bowels in 
this form ; and when it is so given, it should be controlled by 
five drops of laudanum being combined with each dose ; but 
on the contrary, it may prove too astringent to the bowels. In 
that case, as many grains of rhubarb may be given with the 
bark. 

External stimulants are also indicated in this state of the 
system. With regard to blisters, usually directed by physicians, 
there are various opinions. Lind, Cullen, and others, are in 
favour of their use ; but they are objected to by others, except- 
ing when they are applied to remove local affections attendant 
upon typhus fever, as of the brain, the lungs, the stomach, the 
bowels, or the uterus. 

In affections of the brain, Sir John Pringle and others have 
borne testimony to their use. They are also found useful in 



276 LECTURE XXII. 

the typhoid stage of peripneumony, or the peripneumonia 
typhodes, produced by contagion. But in those diseases they 
should not be applied the same length of time as on other oc- 
casions ; i. e. not exceeding six or eight hours, or sphacelus 
will frequently be the consequence in this broken state of the 
system. And in the irritations of the stomach attendant on 
yellow fever, and which frequently usher in that fatal symptom 
the black vomit, they have frequently been found extremely 
useful ; and should another yellow fever be unfortunately 
introduced among us, blisters would be among my earliest 
prescriptions, to prevent that deadly symptom. They are in 
like manner no less beneficial in the removal of the inflam- 
mations of the intestines, attendant upon dysentery, and in 
counteracting the inflammation of the uterus and peritoneum, 
which characterize puerperal fever ; both of which diseases, 
viz. dysentery and puerperal fever, are usually attended with 
fever of the typhoid character. But in all these, as well as in 
typhus fever, it is a very prevalent error, that the application 
of blisters is delayed to too late a period — applied early, they 
are beneficial ; but they are never serviceable in the advanced 
state of fever, with the exceptions that have been noticed. On 
the contrary, they distress the patient and waste his powers. 
So also says Dr. Moore in his Medical Sketches, p. 531.* 

Blisters at this period can certainly be of little use in trans- 
ferring the irritation of the whole system to a particular part, 
(which is the object we should have in view,) for when the 
fluids become the seat of disease, the causes of the irritation 
existing are too constant, and they are too extensive to be thus 
controlled. And as general stimulants, others are preferable, 
even of those used as external stimulants, and without destroy- 
ing or impairing the texture of the parts acted upon. With 
this view, rubefacients, sinapisms, and other stimulant applica- 
tions, are had recourse to, and in my opinion with most ex- 
cellent effects. Burdock leaves dipped in vinegar, sinapisms 
of mustard, vinegar and meal, or the toasted bread covered 
with vinegar and mustard. Salt herrings, garlic, onions, 
applied to the soles of the feet or wrists, frequently afford great. 

* " Notwithstanding," says Dr. Moore, " my having watched the effects of 
blisters with all the attention I am capable of, I cannot assert that I ever knew 
vesicatories of much use." 



TREATMENT OF FEVER. 277 

relief to the head, and sometimes counteract a ferocious deli- 
rium. 

II. The system is to be excited, and its tone supported, by 
means of the diet and drinks of the patient, and especially by 
the liberal use of wine : this may be either given alone, or in 
the form of wine-whey, moderately strong : two or three glasses 
of the best Madeira to a pint of milk ; or it may be given in 
panada, sago, salep, arrow-root, tapioca, cassava, also barley- 
water or caudle, rendered still more stimulant and grateful by 
being combined with some of the spices, as cinnamon, or nut- 
meg, or mace, with the addition of loaf sugar. In this form, 
either of these articles is rendered both grateful to the taste and 
acceptable to the stomach, which has its taste too on these oc- 
casions, and should be particularly consulted by the physician. 
Vegetable nourishments, too, you will recollect, are now to 
be preferred, not only as most grateful and most acceptable to 
the stomach, but on account of their greater antiseptic quality, 
and their having a less tendency to the putrescent fermentation 
than animal food, to which the patient, in this septic state of 
body, has even an aversion. But we place an equal, if not our 
chief dependence, upon the use of wine. The physician, there- 
fore, should attend to its quality, as w^ell as direct its quantity, 
as much mischief may be done by acid wines. As it regards 
strength, old wine is certainly to be preferred — we all know it 
is generally most agreeable. 

Madeira and port wine are the preferable wines for the sick, 
as they are less apt to become acid, and possess more strength 
than claret, which is preferred by some ; and among others, by 
Dr. Moore ! ! (See p. 523.) He, however, admits that he has 
seen the same good effect from Port, Madeira, arid other wines* 
But if you cannot procure wine, brandy or rum diluted with 
water, and sweetened or made into milk-punch, may be substi- 
tuted in its place. Ardent spirits are indeed more grateful to 
a certain class of patients than the best wines ; and where they 
have been accustomed to the use of them in health, they are to 
be preferred. In this case, as well as in some nervous diseases, 
wine and ardent spirits are both proper, and should be retained 
in the Materia Medica, notwithstanding all the prohibitions en- 
joined by temperance societies. 

When you first administer wine to a patient who is delirious, 



278 LECTURE XXII. 

give it a little warmed and sweetened, otherwise he may refuse 
it. For the most part, however, this is one of the few articles 
that men will swallow, whether delirious or in their senses — 
mad or sober they will drink wine. 

What quantity shall be given to a patient in this delirious 
condition, attended with all the other symptoms denoting a 
confirmed state of typhus 1 I answer, from one to five bottles 
a day — observing, however, to give it most freely during the 
remissions in the early part of the day, and less during the ex- 
acerbations, which usually are most violent in the evenings 
and at night. 

A case was communicated to me by Dr. Farmer, of Charles- 
ton, of a gentleman in S. Carolina, who drank eleven bottles of 
Maidera wine in one night, and six the succeeding morning — 
he recovered. 

Porter is another drink frequently made use of in this state 
and character of fever. It certainly combines many valuable 
qualities. It is stimulant, though less so than wine. It is tonic 
from its bitterness ; nutritious, from the materials entering into 
it ; and from the fixed air it contains, it is among the best anti- 
septics we can administer. When typhus prevailed on board 
the Mohawk, among one hundred passengers, I gave to the sick 
porter, as the chief food and physic. 

Yeast, too, for the same reasons, has come into use as a 
powerful antiseptic and anti-emetic in typhus fever ; of this a 
table-spoonful is given every hour. Upon the same principle 
with bark, spirits and wine, yeast is useful in foul ulcers, as in 
anthrax, exciting them to healthy action. But as both porter 
and yeast have a tendency to run through the bowels, where 
the strength is much expended, and especially if the patient be 
already inclined to a loose state of the belly, the purgative ef- 
fects of either would render them dangerous prescriptions. On 
this account great caution becomes necessary. It will perhaps 
be a good rule, where the patient is costive, to give porter; 
but where the bowels show a tendency to diarrhoea to prefer 
wine ; and if diarrhoea actually exists, give the patient spiced 
wine or mulled wine. And it is important to have this properly 
made. Have the spice, either alspice or cinnamon, boiled in a 
tea-cupful of water. Boil a pint of wine. Let three eggs be 
well beaten up with sugar. To this add your spice water, and 



TREATMENT OF FEVER. 279 

pour them gradually into the boiling wine. This is the very 
best mode of preparing mulled wine ; and as you will often be 
asked for directions, it will be well for you to remember the 
form. 

But upon other occasions the bowels may be so confined, that 
instead of these astringents to restrain a diarrhoea, you find it 
necessary to administer to them laxative medicine; otherwise the 
accumulation in the bowels will become an additional source of 
irritation and of vitiation to the whole system — this is a fre- 
quent occurrence. For this purpose an enema should be given 
once in twenty-four hours ; or at most a small dose of rhubarb 
and magnesia; but avoid salts and active purges, especially 
such as operate at the expense of the whole system. Avoid 
Hamilton's jalap and calomel, which are too active at this stage, 
and too apt to disturb the stomach. His observations on pur- 
gatives in typhus I confess have astonished me ! I should just 
as readily think of putting a lancet in a patient's arm in this 
advanced state of fever, as empty his vessels by the active 
purges he has directed. His observations on chorea are an 
equally exceptionable part of his work ; yet his .work is the 
work of an elegant scholar, and one of the most accomplished 
physicians of the age. Such I considered him at the time I knew 
him. I had an opportunity of witnessing his practice at the In- 
firmary of Edinburgh. Although it is sometimes necessary to ad- 
minister cathartic medicines in this malignant form of fever, it 
is more frequently necessary to restrain the evacuations than to 
solicit them ; and that too, even where the contents of the bow- 
els are offensive. And here let me make a remark deserving 
your attention, that you cannot remove the putrid contents of 
the bowels, and that the more you purge your patient the more 
offensive the contents of the bowels become ; for the weaker the 
patient the greater is the putrefactive tendency in the contents 
of the bowels; for the digestive process being impaired, the less 
is its control over that fermentative process that induces this 
oppressive state of the contents of the bowels, the tendency of 
which is to induce a diarrhoea. Anodyne medicines become 
necessary to correct these excessive discharges. A convenient 
formula for this is the following : 3i. laudanum ; §i. sp. lavender; 
Siij. mint or cinn. water — a table- spoonful every hour, or after 
every large evacuation : spirits of lavender alone is also useful. 



280 LECTURE XXII. 

Sir John Pringle recommends the chalk julep in these cases, to 
be given in conjunction with a few drops of laudanum, after 
every loose evacuation. 

The following is a very good and agreeable formula : Gum 
Arabic, 3i. ; chalk, 3i. ; aq. menth. giij. ; elix. paregor. gss. M. 
Coch. mag. post. sing, sedes. Or laudanum may be given in 
warm wine, mulled with cinnamon and sugar. Burnt brandy 
and water, with cinnamon, a flannel bandage to the bowels, 
and spirituous applications, occasionally renewed, will be found 
valuable. In some instances, this disturbance or irritation is 
not confined to the bowels, but involves the stomach, producing 
an immoderate vomiting. 

The means to be employed for the purpose of restraining 
this, are various. 

1. Riverius's mixture, with mint-water ; 2. Mint-water and 
laudanum ; 3. Soda-water, mead or spruce-beer ; 4. Lime-wa- 
ter and milk, equal parts ; 5. Milk alone ; 6. Porter — alone or 
with lime-water ; 7. Spirits or brandy and water, made strong ; 
8. Cayenne pepper; 9. Ice, in pills; or, 10. Give nothing. Let 
the stomach rest. By thus withholding drinks or medicine, 
the tone of the organ may be recovered. 

III. A third means of improving or preserving the strength of 
the patient, is to prevent every unnecessary waste of his excite- 
ment : his room should be kept dark, lest the light of the day, 
of the fire, or of a candle, should keep him watchful. All noise 
should be avoided — loud speaking in his chamber especially, 
though it may not awake him, still disturbs his sleep, occasion- 
ing dreams. Do not suffer him, in this exhausted state, to waste 
his powers by getting out of bed ; and in all his movements 
assist him. Instead of going to his night-chair, let him use a 
pan or a dirty sheet ; and provide him with a urinal, that he 
may have no occasion to rise for the evacuation of his water. 
Even in giving him his drinks or his food, do not allow him to 
waste his strength by his exertions to assist himself; — support 
him ; — and in changing his dress, the same assistance should 
be rendered. The same system of economizing the strength of 
the patient in convalescence, should also be carefully observed. 



281 



LECTURE XXIII. 



TREATMENT OF THE TYPHOID STATE OF FEVER, 



II. A second indication in the treatment of the typhoid stage 
of fever, is to counteract the putrescent state of the system. 
which more especially appears in the fluids, though not exclu- 
sively so; for the solids, too, more or less lose their cohesion 
and powers of contraction. 

The means of fulfilling this indication are, 

1st. To continue the various excretions by the remedies 
which have already been mentioned, especially attending to the 
important function performed by the skin, inasmuch as it is 
the office of the function of perspiration, in health, to convey 
out of the body noxious, saline, and other materials. It is 
doubly necessary when the fluids are in a diseased condition. 
The accumulation from the want of this excretion must conse- 
quently be highly dangerous to the constitution, and an aggra- 
vating cause of the existing disease. Continue, therefore, the 
use of such remedies as act upon the surface, but at the same 
time employ those which are the least debilitating. Of these 
the aristolochia serpentaria is among the best. The dorstenia 
contrayerva was once much in use as a cordial sudorific, but 
it has given place to the Virginia snakeroot. Small doses of 
antimony especially, combined with a small quantity of opium, 
merely sufficient to prevent them from affecting the bowels, 
may also be administered, if the debility should not otherwise 
forbid the use of these medicines ; but usually this is a hazard- 
ous prescription at this period of the disease, particularly with- 
out the opium. The sp. mind, and laud, is less so, but even this 
should be given with great caution ; for it is not only the ob- 
25 



282 LECTURE xxm. 

ject in view to administer sudorifics, but also at the same time 
to excite, and stimulate, and to preserve the tone of the sys- 
tem. Wine-whey is one of the best means we can direct in 
addition to the others which have been mentioned, to effect this 
object, in this state of body. It is also important to attend to 
the bow T els — the lower intestines in particular. They should be 
regularly emptied, once in twenty-four hours ; otherwise diar- 
rhoea may be the effect of the irritation produced by their acrid 
contents, as well as by their mechanical accumulation. This 
is not all : by their retention, the whole state of the fluids may 
be rendered still more malignant by the reabsorption of the 
malecontents, particularly of the lower tract of the intestines. 
For the purpose of relieving the bowels in the typhoid state of 
fever, I have been much in the habit of using the following 
form of an enema, which I consider peculiarly calculated to 
correct the septic contents of the bowels, as well as to evac- 
uate them. Vinegar, §i. (i. e. coch. ij. mag.) ; yeast, gi. to gij. 
molasses, gi. to gij. (coch. i.) ; water, gviij. M. To be admi- 
nistered cold or milk-warm. 

2dly. A second means of fulfilling the indication now under our 
consideration, is frequently to cleanse the surface of the body 
itself, by washing it with vinegar and water, (applied at a mo- 
derate temperature ; i. e. from 40° to 60°,) three or four times 
a day, w r hen the body is much heated, and the skin dry. It is 
necessary, however, to observe two exceptions to this rule. 

1st. When the heat of the body is too low — reduced below 
the natural standard — and the power of generating heat is at 
the same time much impaired. 

2d. Another exception to the use of cool, or cold applica- 
tions, is the presence of local diseases, conjoined with this 
typhoid state of body, as in dysentery, peripneumony, puerperal 
fever. In those cases, cold applications are injurious— tepid 
washings with vinegar and water, or with spirits and water, 
should then be employed.* And it is to be remarked, that tepid 
water, applied to the body, conveys off the caloric as well as 
the cold affusion, and partly in consequence of more speed of 
evaporation. 

* By tepid water is meant warm, not hot water — not hot to the sensations- 
say from 87° to 97° of the scale of Fah, 



TREATMENT OF FEVER. 283 

Dr. Currie also observes, that he has made use of tepid water 
with advantage in many of those cases where the oppression 
might be dangerously augmented by the sudden stimulus of the 
cold affusion ; but its effects he considers to be not so perma- 
nent as the cold; still he admits it to be as useful in diminish- 
ing the heat, but not as a stimulus to rouse the system at the 
same time into a violent reaction. 

3dly. If the heat of the body is much reduced, and the body 
itself exhibits a livid appearance — if the extremities are cold, 
and the powers are greatly exhausted by which the heat should 
be restored, in that case let the body be frequently sponged 
with warm or hot spirits, and afterwards diligently rubbed with 
a coarse towel or with flannel. Make use of a bath rendered 
stimulant by its temperature, and still more so by the addition 
of spirits, Peruvian bark, and the aq. ammon. occasionally, 
adding the last article while the patient remains in the bath. 

4thly. Be careful to remove all excrementitious discharges 
from the apartments of the sick ; with the same view, too, fre- 
quently change the bed, the bedding and the dress of the pa- 
tient ; (for this purpose let a cot and bed be introduced into the 
room to lay the patient upon, that his strength may not be 
wasted by setting him up in a chair.) It will also be well to 
make use of flannel shirts instead of linen ; for flannel not only 
preserves a uniform temperature about the body, but it also 
excites the skin to more vigorous action ; and it absorbs the 
offensive and noxious materials discharged from the surface in 
this state of disease ; and it is by many physicians believed that 
the vinegar shirt, as it is called — that is, a flannel shirt, after it 
is washed, being dipped in vinegar and dried, is preferable to 
flannel without this process. I have seen it used so often, with 
benefit to the patient in this disease, that I really believe it has 
advantages from the acid even thus applied. The vinegar, too, 
may render the flannel more stimulant to the surface, and like 
the vinegar and other acids acting upon the air, it may in this 
way perhaps have some good effect by decomposing the nox- 
ious materials as they are discharged from the surface of the 
body. But whatever opinion we form upon this subject, we 
doubtless must all unite as to the benefits at least of frequent 
changes of dress, and the preference to be given to flannel over 
linen, inasmuch as it is more stimulant to the surface, and bet- 



284 LECTURE XXIII. 

ter calculated to absorb the discharges from the skin, and to 
preserve a uniform temperature about the body of the patient. 

5thly. Preserve the air of the room as pure as possible, by- 
ventilation ; for, as Dr. Fordyce observes in a letter which I 
received from that learned and distinguished physician, a short 
time before his death, " dilution with atmospheric air is the 
great means of destroying contagion, not only as it regards the 
individual, but his attendants and friends." This should be in- 
scribed over every door of the wards of a fever hospital, and 
no less strictly observed in the private apartments of the sick. 
With the same view attend to the size of the room in which 
the patient lies sick — put him in the largest room of the house 
— attend also to its temperature. Be careful, however, not to 
let the bed be too cool at this advanced period of his disease. 
And should his heat be too low, the addition of more clothing 
may become necessary ; but too hot an atmosphere is more to 
be apprehended ; for in our climate, at least, this disease is most 
prevalent in the hottest seasons of the year. So also in the 
southern states, and in hot climates. In a hot climate, and m 
the hot seasons of the year of temperate climates, cool the air 
by frequently sprinkling the floor for the benefits of evapora- 
tion. And that you may purify the air at the same time that 
you cool it, sprinkle it with vinegar ; and if the air be very im- 
pure, as in hospitals, or in courts or prisons, make use of the 
acid gases in general, as they have been lately recommended 
by Guyton de Morveau and Carmichael Smyth, for the pur- 
pose of disinfecting the atmosphere. You will find that the 
fact was known to Sir John Pringle, as early as 1750, that 
the mineral acids will destroy contagion. Johnstone of Wor- 
cester, in 1758, made use of it for this purpose. Guyton de 
Morveau and Carmichael Smyth, at Winchester, have the 
merit of bringing them again into use, and have received the 
grateful acknowledgments of the world for this truly important 
service. They certainly are entitled to thanks for what they 
have done. Nevertheless they cannot justly have ascribed to 
them the merit of originality. Dr. John Johnstone of Birming- 
ham, in his " Account of the discovery of the power of the 
mineral acids in a state of gas to destroy contagion," pub- 
lished in 1803 ; and in his " Reply to Dr. J. C. Smyth" in 1805, 
has triumphantly shown that the disinfecting property of the 



TREATMENT OF FEVER. 285 

acid gases was known and employed by his father in 1758. 
And if you will read a paper, entitled " An attempt to show 
that the use of Acid Fumigations was known before the time 
of Morveau, Smyth, &c." published in the American Medical 
Recorder, (vol. iv. p. 133,) by its then editor, Dr. Ducachet, 
you will see that it was well known to Boerhaave and his 
commentator Van Swieten, half a century before Dr. Smyth 
laid claim to the discovery ; and that the celebrated Dr. Mead, 
who lived at the same time, understood it well. In his six hun- 
dred and fifth Aphorism, Boerhaave speaks largely of the 
virtue of acid fumes ; and in his Elementa Chemise, torn. ii. p. 
269, expressly says, " totus acidus vapor totum aera emendat" 
His annotator, too, was evidently perfectly acquainted with the 
disinfecting power of acid vapours. Indeed you will find it 
clearly demonstrated in that paper, that it was not unknown 
even in ancient days. Dr. Ducachet shows conclusively, that 
it was known to Homer, since the bard represents Achilles as 
resorting to the use of sulphurous fumes to purify a vessel, in 
which he intended to offer a libation to the gods for the success 
of his friend Patroclus ; and as he tells how Ulysses, on his re- 
turn to Ithaca, fumigated his house with sulphur, to free it Of 
its pollution by the blood of certain troublesome visiters who 
had been slain there. 

" With fire and sulphur, cure of noxious fumes, 
He purged the walls and blood polluted rooms." 

Odyssey, book xxii. lin. 529. 

Indeed, the existence of the verb d-mooi, in the Greek language, 
which signifies to purify with sulphur, sulphure lustro, shows 
that the value of acid fumigations by means of volatilized sul- 
phur — in other words, by the sulphurous acid, was known 
familiarly to the Greeks. But I must refer you to the disserta- 
tion itself. 

The following are the compounds which are employed for 
the purpose of supplying these two gases, viz., the nitrous acid 
gas of Smyth, and the oxygenated muriatic acid gas of Guy- 
ton de Morveau. The first is prepared as follows : 

Take of the nitrate of potash pulverized, gss. ; put it into 
a saucer ; pour upon it the same quantity of the sulphuric acid : 
25* 



286 LECTURE XXIII. 

by exposing it to heat upon a chafingdish, the decomposition 
will be facilitated ; the sulphuric acid generated is immediately 
extricated and diffused through the apartment. 

The oxygenated muriatic acid gas, the chlorine gas, as now 
called, is prepared in the following manner : 

Common salt, ^iv. ; oxyde of manganese, 3L ; sulphuric acid, 
gij., diluted with water, gij. ; put over a chafingdish of coals. 
See Proceedings of the Board of Health of Manchester, p. 42. 
But the Professor of Chemistry will give you every detail upon 
this subject. 

As I before explained to you, the mode in which these gases 
operate in disinfecting the air, and in destroying the odour of 
putrid materials, is supposed by Crawford and by Dr. Garnett 
to be by combining with the hydrogen gas, which is believed to 
hold these noxious matters in solution, or at least which holds 
a very close and intimate connexion with them. The air, it is 
known, is rendered instantly pure. The effluvium which arises 
from the decomposition of animal and vegetable matter, and 
which so sensibly affects our smell, has been ascertained to 
consist either of sulphur, phosphorus, or ammonia, or these 
combined, and held in solution by union with hydrogen. None 
of these combinations are offensive when uncombined. Hence, 
then, it is our object to separate them. This is effectually ac- 
complished by these acid gases. The oxygen they contain 
combines with the hydrogen, and the material or materials held 
in solution or in combination are precipitated, and consequently 
rendered harmless. And that these gases are no less useful in 
destroying the matter of contagion, has been most abundantly 
established. 

6thly. Tonic medicines furnish another means of counter- 
acting the putrescence of the system. With this view the bit- 
ters already noticed, both in their watery and spirituous forms, 
viz. the infusion of columbo and quassia, or of chamomile and 
orange-peel, or in the form of the tinctura amara, may still be 
continued, as among the best means of giving tone to the sto- 
mach and other organs concerned in the digestion and assimila- 
tion of our food, at the same time that they lessen the morbid 
sensibility of the whole system. The addition of the mineral 
acids is no less beneficial in this septic state of the system. 
Not only as tonics, but by their chemical agency, they may 



TREATMENT OF FEVER. 28? 

also be useful in their action on the system — at least upon the 
contents of the intestinal canal, in which the putrefactive fer- 
mentation predominates while the digestive process remains 
impaired. Bark, in its various forms of substance, infusion, 
decoction or tincture, and especially in combination with snake- 
root or the sulphate of quinine, should also be given in this 
stage of fever — in a hot climate particularly, it is indispensably 
necessary ; so much so, that the practitioners of the West In- 
dies introduce it in every possible manner, by the stomach, by 
the skin, and by injection, and frequently all combined. And 
so tenacious are they on this point, that when administered by 
injection, if it should be rejected by the irritable bowel, and 
laudanum is not sufficient to cause it to be retained, they have 
recourse to mechanical pressure upon the intestine to secure its 
retention. It is a common practice, I am told, for Mingo to 
sit by the half hour with his compress, plugging up the anus, 
after a dose of bark has been thrown up. 

" When a dangerous debility, and a train of malignant symp- 
toms are threatened," says Dr. Moore, (Med. Sketches, p. 507,) 
" the bark is found the most powerful means of preventing 
those symptoms ; and notwithstanding its astringent qualities, 
frequently promotes a salutary diaphoresis more effectually 
than any of the medicines which enjoy, from prescription, the 
title of diaphoretics." He adds, "When the patient is out of 
danger, you may account for this in the best manner you can, 
and settle the point at leisure. Whether in producing these 
effects it has acted in the character of a tonic, diaphoretic, or 
antiseptic — the nature of the disease being ascertained, and the 
alimentary canal entirely cleansed, the bark should be given 
without waiting for very distinct remissions. To wait for such 
when the disease appears to be the nervous malignant fever, is 
to wait for what will not happen — depriving the patient of a 
probable chance of recovery, and allowing him to incur the 
risk of sinking suddenly into such a state of weakness as will 
render the bark, and all other medicines, of no avail." Medical 
Sketches, p. 507-9. 

7thly. Vegetable nourishments are at this time peculiarly in- 
dicated ; and animal food, even in the form of soups, should be 
rigidly avoided. Very fortunately, however, nature herself 
rejects them as offensive — even their smell is disagreeable to 



288 LECTURE XXIII. 

the patient in this state of body. On the other hand, the appe- 
tite for acids is strong and eager. Fresh fruits, as strawberries, 
grapes, oranges, limes, lemons, in their season ; or roasted ap- 
ples, currant-jelly, cranberries, when fresh fruit cannot be 
obtained, will also prove a very grateful and valuable addition 
to the nourishments of the sick — but like the yeast and porter, 
they must be given with great caution, lest they prove too pur- 
gative in their effects. But while you can command the juice 
of the grape, you need be at no loss for a very effectual means 
of preserving the tone of your patient. This, at least, is my 
sheet-anchor on these occasions. Attend, too, to the time and 
manner of administering food, as well as the quantity given. 
Food, in many cases, should be given every half hour. In 
cases of stupor, arising either from an accumulation of blood, 
or of serum upon the brain, or from an exhausted state of the 
sensorial power, or where there is a great propensity to sleep 
without such apoplectic pressure, the patient, in that case, must 
be roused frequently to take his nourishments or his drinks. 

Insensibility takes place to such a degree sometimes, that 
the patient takes the food or his medicine into his mouth, and 
retains it there without swallowing it : in that case, excite him 
by loud speaking, and actually commanding, in a loud tone of 
voice, directing him to swallow it. Present another spoonful, 
and another — he then swallows. This degree of insensibility is 
a very unfavourable symptom. In this critical situation of your 
patient, food or medicine should be given in small quantities, 
but frequently. Recollect that in large quantities you produce 
great irritation — vomiting, purging, oppression, restlessness ; a 
renewal or increase of fever are oftentimes the consequences 
of such excess. Remember, however, to continue the use of 
wine or porter, preferring one or the other as circumstances 
may point out. But suppose the stomach rejects nourishment 
or medicine, or both ; in that case make use of enemata for 
conveying both medicine and diet. 

We told you of the skin as an important medium of com- 
munication, a sort of second stomach ; the lower bowels may 
be considered as a third stomach, and prove a valuable re- 
source on many occasions. Milk punch, arrow root, starch or 
sago, in wine-whey, may thus be administered as well as medi- 
cines. Another observation deserving your attention is, that 



TREATMENT OF FEVER. 289 

in this extreme prostration of the system, the patient is fre- 
quently unconscious of many of his sufferings, and only signi- 
fies them by his moanings, but without intelligence sufficient to 
refer them to the particular part which may be affected. Of 
this he is indeed himself insensible. In some instances it may 
arise from an accumulation of faeces ; an enema will in such 
cases afford him relief; or it may proceed from a collection of 
urine in the bladder, which the patient should be urged to 
evacuate. In case of inability to do so, the catheter should be 
employed. The irritation of a blister which requires dressing, 
soreness of the mouth or throat from the use of mercury, or 
from aphthae, not unfrequently the attendant upon the last stage 
of fever, may be the source of the patient's distress. In the 
latter case, yeast with honey and borax, are among the best 
applications, either in the form of a gargle, or a wash, if 
the patient has not strength to gargle his throat. It is proper 
for me to state to you, that Dr. Bard in such cases is fond 
of small doses of mercury, i. gr. two or three times a day 
• — perhaps the very excitement produced by mercury may 
be useful in doses of this sort. Soreness from long lying in 
bed, and from the pressure of particular parts, in consequence 
of remaining long in the same position, will not only occasion 
pain, but in some cases active inflammation and sphacelus, de- 
pending upon the condition of body, are the consequences, and 
require the prescriptions of the physician. In this debilitated 
and vitiated state of the body, the most stimulant dressing and 
applications become necessary; such as cloths wet with yeast: 
lint moistened with the pyroli^neous acid ; the yeast poultice, 
or a dressing of the basilicon ointment, may be useful, preserv- 
ing the parts very clean by repeatedly washing them with hot 
water, with the addition of a proportion of rum or brandy. 
To all these varied sources of suffering, the attention both of 
the physician and the nurse should be given in the sick room. 
The symptoms of recovery and convalescence next fall under 
our consideration. How is the patient known to be convales- 
cent? This may be known — first, by attention to his vital 
functions. The pulse is calm, more full, soft, and generally 
slower than natural, and more regular, excepting in yellow 
fever. But quickness frequently remains sometime in con vales- 



290 LECTURE XXIII. 

cence from fever. The respiration is more regular, but also, 
like the pulse, slow, and sometimes attended with sighing. 

Secondly. The natural functions manifest a change which 
indicates a solution of fever, and the commencement of reco- 
very. The tongue and lips show the returning secretions ; they 
now become moist, and the tongue clean, especially at its 
edges ; it is also of its natural colour, losing the crimson or 
brown hue. The fur upon the middle of the tongue too, appears 
more loose, and easily to be detached. The teeth, gums and 
lips appear cleaner, and freed from the sordes that were ob- 
served upon them during the continuance of fever. The skin 
likewise shows a returning natural temperature, with a general 
moisture upon its surface. Indeed, the vessels upon the sur- 
face sometimes become so patulous, that there is a great pro- 
pensity to a profuse discharge by sweat, especially during 
sleep. This, however, for the most part, is a favourable symp- 
tom, and shows a more complete solution of the fever, than 
almost any other single symptom, except when that sweat is 
attended with coldness of the extremities. 

The kidneys too, manifest the change induced in their secre- 
tion. The urine deposites a large sediment, and is frequently 
discharged in greater quantities. The appetite returns, not only 
for food, but even the artificial one for snuff, coffee, and other 
accustomed stimuli. The bowels too, become more regular; 
the stools take place spontaneously ; they assume their natural 
colour ; they are less fluid, the thinner parts of the contents of 
the bowels being taken up by the returning healthy action of 
the absorbents. They also acquire more consistency, assum- 
ing a " figured shape," as Dr. Home denominated it. Not 
unfrequently, too, this returning tone of the intestinal canal is 
manifested by an occasional discharge of wind, and that too 
accompanied with a loud report. This circumstance shows 
not only the contractile state of the sphincters, but that the 
bowels are now sensible of their contents ; that they can now 
make distinctions ; whereas, before they did not distinguish 
what was passing, but let all go indiscriminately. 

On this subject let me tell you a little anecdote, which I had 
from Dr. Rush. The Doctor had a patient extremely ill, in the 
Pennsylvania Hospital, and for whose recovery he experienced 
great anxiety. He left him very low, not expecting his recovery. 



TREATMENT OF FEVER. 291 

The old nurse of the house was no less attentive to his situa- 
tion ; her anxiety kept pace with the Doctor's. She watched 
the patient very narrowly ; nothing escaped that she did not 
know. In a short time a change was effected. In a little 
time, down came old Molly, the nurse, who felt as much anx- 
iety on these occasions as the Doctor himself. The old lady 
impatiently asked for the Doctor. — " Well, Doctor, our patient 
is out of danger !" "Ah ! indeed ! how do you know, Molly?" 
" Ah !" says she, " I have one sign, Doctor, that never, never 
deceives me." " Well, tell me nurse, what is that V- " Oh ! 
you must excuse me, Doctor, but I know he is a great deal 
better." " I must know that secret, nurse." The Doctor was 
determined to sift Molly to the bottom. " Well, saving your 
presence, Sir, if I must tell you, he just this moment let go a 

most terrible ." When you get this signal, this " signum 

salutis," you will remember that your patient is in a good way. 

In some instances the patient, in convalescence from fevers, 
has a great propensity to sleep, and which to the family or 
friends is a source of some uneasiness. This circumstance is 
favourable to the recovery of his strength, as it prevents that 
waste of excitement which otherwise takes place. Though it 
be excessive, I still call it natural sleep ; that is, when the other 
symptoms are favourable which have been enumerated. Be 
careful, however, to distinguish between this propensity which 
is so common in the advanced state of fever, from stupor or 
coma. This will readily be done, by examining the iris and 
its power of contracting ; attentively observing the other func- 
tions of the system, such as the state of his pulse, and his 
breathing, which are natural. His natural functions too, as 
well as the vital, go on very regularly, and when he is awak- 
ened, it is done with ease, without much exertion of his at- 
tendants, and he awakes composed. It will also be necessary 
to rouse the patient frequently, even from this natural sleep, to 
give him the necessary medicine and nourishment. Be par- 
ticular too, to change his position in bed frequently. By this 
means you relieve one set of muscles while you exercise 
another. This leads us to notice the treatment proper to be 
employed during convalescence. 

1. Of medicines. 

Tonics are now manifestly necessary, for the purpose of aid- 



292 LECTURE XXIII. 

ing the digestive and assimilating process, and thereby to cor- 
rect that tendency to fermentation which still exists, and indeed 
which predominates, while the tone of the stomach and of the 
whole system remains impaired. With this view, I usually 
direct the bitter infusion — either the simple, viz. composed of 
gentian gss., orange-peel 3ij., water gxx., boiled to ^xvi., or the 
more compound one mentioned before, with a combination 
of rhubarb and the carbonate of soda, or in the form of tinc- 
ture. If the debility is excessive, and is attended with profuse 
sweating, I generally direct the elixir of vitriol to be taken in 
combination with the bitters ; about xv. or xx. drops four times 
a day, but not with the rhubarb and soda, these now should be 
omitted. Some recommend the muriatic acid in doses of gtt. 
x. or xij., to be given in each dose of the bitter infusion, or of the 
tinctura amara, every three or four hours ; and if they prove 
purgative, five drops of laudanum are combined with each dose. 
In the practice of physic of Dr. Wm. Fordyce, you will see 
this acid particularly recommended in malignant fevers, and as 
a gargle in the sloughs and ulcers of cynanche maligna. 

Not long since a reward was bestowed by the king of Prus- 
sia upon Professor Reich, of the University of Erling, in Fran- 
conia, for the disclosure of his secret, which proved to be no 
more nor less than the muriatic acid. Can it have effect in 
this state of body in guarding against those combinations in the 
bowels, and in the circulating fluids of the system, which take 
place in a typhoid state of body ? or of breaking up those com- 
binations when they are already formed ? If these acids are 
useful in decomposing fluids out of the body, assuredly they 
may be equally salutary in decomposing morbid compounds 
within the body. 

Be no less attentive, at this time, to the condition of the 
intestines ; and for this purpose, occasionally administer an 
enema, or a small quantity of rhubarb or of magnesia, particu- 
larly of calcined magnesia, which is freed from its fixed air. 
In this respect it is preferable to the carbonate, which contains 
seven-twelfths of fixed air. Or a single pill composed of a grain 
of gamboge and of aloes may be administered ; or the addition 
of the elixir proprietatis to the tinctura amara, say of the former 
Si., to Sij. of the latter. 

2d. The food of the patient should also still fall under the 



TREATMENT OF FEVER. 293 

physician's special direction, during the period of convalescence 
— his food should be of easy digestion. Accordingly, too, as 
the vitiation of his system may have been induced, and as it 
may still continue, let him in that case employ a large propor- 
tion of vegetable nutriment — I mean of those articles abound- 
ing in mucilage, as the arrow-root, rice, tapioca, sago, salep, 
with a due quantity of wine or brandy and aromatics ; at the 
same time allowing him the moderate use of the fresh fruits of 
the season. Let him return gradually to the use of animal diet, 
and then, as before observed, let it consist either of game, such 
as quail, pheasant, and other wild fowl, or venison ; or a 
roasted oyster may be given — not raw. The old meats, too, 
such as beef or mutton, are preferable to chickens, lamb, or veal 
— roasted and broiled are also preferable to boiled, as they con- 
tain more of the nutritious juices of the meat ; and they should 
be taken in this state of the meat, well seasoned with the usual 
condiments of the table, pepper, salt, and mustard. Avoid 
pork, or meats dressed with much oil or butter — they are not 
only in themselves oftentimes offensive to the delicate stomach, 
but being difficult of digestion, they readily become the means 
of occasioning some derangement of the digestive organs, and 
of renewing the febrile irritation. His food should be taken 
frequently, but in small quantities. Let him eat four or six 
times a day, but moderately at each time. The neglect of this 
rule has led practitioners to disapprove of the use of animal 
food, especially taken in a solid form, during convalescence ; 
but under this restraint it may be taken with safety, and indeed 
is more easy of digestion than most other nutriment. His 
drinks should be Madeira wine and water, porter, spirits or 
brandy and water. Let him avoid table beer, cider, and 
lemonade ; they are too acid and acescent, and consequently 
debilitating. Tea and coffee, too, should not now be employed ; 
they take the place of more substantial, more stimulant, and 
more nutritious articles of diet. Chocolate is more nutritious, 
and on this account more proper ; but it should be carefully 
prepared, and freed from the grease and oil which enter into it, 
and which are frequently blended with it by the manufacturers 
of that article of diet. 

3d. The exercise of the patient, the proper time of taking it, 
the kind of exercise, and the degree of it, should be directed by 
26 



204 



LECTURE XXIII, 



the physician. As soon as the patient can take exercise with- 
out fatigue, he should go out into the open air ; this stimulus is 
no less necessary than useful. Riding in an easy carriage is the 
best mode of exercise while he remains debilitated ; but it 
should be so moderate that he can return without fatigue ; 
otherwise it will do him more injury than benefit. He should 
be careful, too, to avoid excess of bodily exercise, even in his 
chamber. The very exertion of dressing, writing, or of 
shaving himself, should all be done with great caution at this 
time. Mental exercise also should be guarded against, as in 
conversation, reading, attention to business, company, &c. 
Excesses in any of these occupations readily induce a relapse, 
while the body remains in this irritable state. Remember the 
brain is a gland ; therefore, economise its excretions, whether 
in thought, word, or deed — whether in mental or in bodily ex- 
ercise ; for the least indiscretion or excess in these respects has 
been known to induce a return of fever, and which is always 
more formidable in its symptoms and in its consequences than 
the original attack. The sequelee of fever, the consequences of 
it to the body and mind, merit your attention. 

1st. The most usual of these, after a long-continued fever, that 
the physician is called upon to prescribe for, is a swelling of 
the legs and ankles ; but in some cases an accumulation of 
fluids in various cavities of the body, producing hydrothorax 
and ascites, is thus induced. A temporary anasarca, thus in- 
duced by loss of tone in the absorbents, and debility of the 
heart and arteries, and nervous system, is of very frequent oc- 
currence after fever. An occasional and very mild cathartic 
may be administered, if the bowels be not in a regular state ; 
this should be succeeded by the use of iron and bitters. There 
are different modes of exhibiting the iron ; it may be given in 
rust ; taken mixed in syrup of ginger, gr. x. three times a day. 
Others prefer the filings of iron made up into pills, with the ex- 
tract of gentian, two pills of gr. v. each, to be taken three times 
a day. Chalybeate wine is another form of administering this 
powerful tonic ; gss. of the filings should be infused in a bottle 
of old hock ; after standing a few days in a proper tempera- 
ture, occasionally shaking it in that time, half a wine-glassful 
should be taken three or four times a day. This is one of the 
most effectual, and one of the most agreeable modes of taking 



TREATMENT OF FEVER, 295 

iron, to those who like a glass of hock. In some instances I 
have administered with good effect an electuary composed of 
bark, iron, and cloves, in the proportion of gij. bark, 3ij. iron 
filings, 60 cloves, q. s. syrup ; a tea-spoonful of this may be 
taken alone or mixed in a glass of Port or Madeira wine, three 
or four times a day. The tincture of gentian, called also tinc- 
tura amara, or the bitter infusion, may also be occasionally 
continued. A flannel roller applied to the legs and ankles — 
friction with a flesh-brush, and bathing the limbs with brandy 
or rum, or these all combined, are among the best local appli- 
cations which can be employed. Blisters, applied to the inside 
of the ankles, I have also made use of with benefit, in cases of 
this nature, where the swelling of the limbs remained more 
than ordinarily tedious. A Mr. C. from the West Indies, in 
1795, was a remarkable instance of this kind. He was pale, 
and his whole cellular membrane loaded with water. Blisters 
and the chalybeate electuary, with aloes, with the free use of 
gin toddy and other stimulant diuretic drinks, were his reme- 
dies. In his case the stimulant effects of blisters upon the 
sluggish absorbents and circulating vessels were obviously 
beneficial. But much also may be done by attention to diet 
and exercise. Not only animal food, but the free use of condi- 
ments, should now be recommended in this state of body — mus- 
tard, horse-radish, and Cayenne pepper, should be taken freely. 
The following stimulant and diuretic drink may now be taken 
with peculiar advantage : it is composed of horse-radish, mus- 
tard seed, parsley roots, of each a handful — these are infused 
in a gallon of hard cider — not acid cider. This infusion is to 
be made in an iron pot, or if in an earthen one, add an ounce of 
iron filings or rusty nails ; let it stand near the fire, where it can 
have the benefit of a moderate degree of heat — to be strained 
after standing two or three days and bottled ; a wine-glassful 
three or four times a day. Gin and water, or an infusion of 
juniper berries, may occasionally be substituted. 

This species of dropsy, however, is not to be treated in the 
manner recommended by Dr. Moore in his Medical Sketches, 
viz, by jalap, nitre, and other depleting remedies ; for such 
accumulation of fluid in the cellular membrane is not referrible 
to increased effusion, but to loss of power in the absorbent ves- 
sels, and diminished action of the extreme arteries, and conse- 



29G 



LECTURE XXIII. 



quently retarded circulation in the veins — not the increased ac- 
tion of the exhalents, proceeding from an increased excitement 
and plethoric state of the arterial system. Dr. Moore does not 
appear to have been apprised of this important distinction, and 
which is especially important as it regards practice. 

2d. Glandular swellings, ending sometimes in inflammation 
and abscess, are among the consequences of long-continued fe- 
vers, especially in hot climates and the southern states. These 
originate in debility of the small circulating and absorbent ves- 
sels, producing congestion in the glands — for glands are made 
up of a congeries of small vessels, which in such debilitated 
habits of body are apt to become affected. These congestions 
sometimes appear in the glands of the neck — of the axilla — in 
the groins — but more frequently in the liver and the spleen. 
Tonics, especially the mineral tonics, are among the most 
effectual means of removing such obstruction ; but if inflam- 
mation be induced and suppuration be the consequence, they 
should be opened as early as possible, to prevent or to remove 
hectic fever, and followed by the free use of the Peruvian bark, 
the nitric acid,* and other tonics ; at the same time that stimu- 
lant dressings should be made use of, to excite the healthy 
action of the vessels of the part affected. 

3d. Biles are in some instances the consequences of fever, and 
the vitiated state of the system. These are only to be coun- 
teracted by improving the digestive process, (not upon the 
principle that all diseases originate in the stomach, as is main- 
tained by many writers, particularly Broussais of France, a 
late innovator and reviver of the Brunonian doctrines,) but by 
enabling the organs concerned in that process to furnish the 
blood with a healthy chyle, at the same time that the tone of 
the other functions is restored by a stimulant and nutritious 
diet. It is also a good rule in this case to discharge the con- 
tents of such imposthumation as soon as possible. 

4th. The mind as well as the body remains debilitated, and 
manifests this debility in all its faculties — in a deranged condition 
of the internal senses, in a loss of the memory, a diseased state 

* The manner of giving it is thus: nit. acid 3i., water feij., sweetened; a 
wine-glassful every two hours; the acid is to be gradually increased to 3ij. to 
a quart ; not that the nitrous acid has any specific operation upon the liver, as 
many have supposed. 



TREATMENT OF FEVER. 297 

of the imagination, and an enfeebled condition of the under- 
standing. Such was the situation of a reverend gentleman 
under my care. That gentleman is naturally of a very sensi- 
tive nervous system — a man of fine taste, distinguished both 
for his capacity and his acquirements. After a tedious remit- 
tent, and typhoid fever supervening, all these morbid effects re- 
mained in the mind when his bodily functions had become 
comparatively restored. Such was the critical state of his 
imagination, that he had very nearly been led to commit an act 
of violence upon himself. But by time, by the use of tonics, 
and a journey, he has fully recovered both his mental and his 
bodily powers. In such cases in general, recovery may be 
predicted from the prudent use of the means that have been 
pointed out. In the communication to the physician (D* 
Bard) by whom I was consulted in the case referred to, I ex- 
pressed this prognosis with great confidence. This hypochon- 
driacal state of mind is especially to be counteracted by exer 
cise, in which the mind is to be gratified at the same time — as 
by a journey through a variegated pleasant country, and par- 
ticularly when attended by a cheerful and intelligent com- 
panion. A return, too, to ordinary business, when the strength 
will permit it to be done, is also among the most important 
means of restoring the mind to the healthy exercise of its 
functions. 

These observations finish our view of general fever. I 
hope it has not appeared tedious to you; if it has, my sense of 
its importance must be my apology. We shall next proceed to 
call your attention to the different forms or types of fever, and 
to point out their discriminating characters. 



26* 



298 



LECTURE XXIV. 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 



We have seen fever as consisting in an irritation of the 
whole system ; as affecting the brain and nervous system ; as 
showing itself in the moving fibres ; as deranging all the func- 
tions both of the body and mind, and at last affecting the 
fluids ; and these again reacting upon the system, producing 
secondary or typhus fever. The general symptoms of fever 
have been described ; its various causes have also been pointed 
out, whether predisposing, exciting, or proximate, with the 
manner of their operation, as far as facts have enabled us to 
trace the connexion between causes and their effects ; a sub- 
ject always involved in obscurity, but peculiarly so as it regards 
the phenomena of the animal economy in a state of disease. 
The general treatment of fever has also been laid before you, 
corresponding with the various forms and stages which fever 
assumes, whether consisting in a state of simple excitement, or 
that which involves a morbid state of the fluids, which we have 
denominated the complicated excitement of the system. 

We shall now proceed to notice the various forms of fever, 
and to enumerate the characteristic symptoms of each. A pre- 
liminary explanation of two or three terms becomes necessary 
on this subject. When speaking of particular fevers we make 
use of the term paroxysm, by which we mean that period of 
the disease in which the fever is present, as opposed to apy- 
rexia or intermission, when fever is absent. 

We also use the term remission, to denote merely a sensible 
abatement of fever, as opposed to the increase of fever called 
exacerbation. 

Crisis is another term much employed when speaking of 
fever and other acute diseases, and denotes the tendency to a 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 299 

perfect termination or solution of the fever, meaning more 
especially continued fevers ; but does not apply like apyrexia 
or intermission to the conclusion of a single paroxysm. This 
name crisis is derived from the Greek word */»«.«w, to pass 
through. It therefore also has a reference to the discharges 
from the system of a supposed morbid matter, or something 
noxious, which had been the cause of fever, or may have been 
engendered in the system as the effect of the fever. These 
salutary discharges, so terminating the disease, whether by 
hemorrhage, by vomiting, by urine, by stool, by sweat, or by 
eruptions, or by creating a new local inflammation, were ac- 
cordingly called critical discharges, critical eruptions, &c. In 
some instances, indeed in most cases, these events are favour- 
able, producing a complete solution of the fever ; but in others, 
they produce a contrary effect, and not only fail to remove the 
disease, but are followed by an exacerbation or aggravation of 
all the symptoms of fever. Crisis, accordingly, is sometimes 
considered as favourable ; and, under other circumstances, un- 
favourable — perfect and imperfect. 

A judgment must then be formed from the circumstances 
attendant upon such inordinate changes which occur in the 
progress of a disease ; hence some have derived the term crisis 
from Kgiva, to judge, because a favourable or unfavourable prog- 
nosis or judgment of the event is now to be formed, dependent 
upon the discharges or symptoms which are now presented. 
The days, too, when such changes occur, are hence called 
critical days, and from the last mentioned etymology they are 
also called judicial days. Those days on which such occur- 
rences take place, and on which diseases are particularly apt 
to terminate, received great attention from Hippocrates, Galen, 
and other ancient physicians ; but at that time, when dis- 
eases were less under the control of human reason than they 
are at present — when nature, not art, directed the progress of 
diseases, those changes were deemed of more importance in 
making up a prognosis of the event, whether favourable or 
otherwise, than they are at this day. Still, though these violent 
changes are of less frequent occurrence at the present time, the 
study of them is important with the view to the prognosis. 

The days which Hippocrates has pointed out as those on 
which fevers are most apt to terminate, or when changes most 



300 LECTURE XXIV. 

frequently occur, are the 3d, 5th, 7th, 9th, 11th, in those cases 
in which the tertian type of fevers appears to show a prevailing 
influence ; and on the 14th, 17th, and 20th, in those in which it 
assumes the quartan character. Even among the ancients, the 
correctness of this view of the tendency of fevers to terminate 
on particular days was called in question. Herophilus denied it 
in toto. Asclepiades considered the whole doctrine of critical 
days as idle and nugatory. Celsus even derides it as not only 
grossly inconsistent with itself, but as originating in the cupidity 
of physicians, who for the sake of gain were desirous of pro- 
tracting their attendance, and multiplying the number of their 
visits.* Langius observes, " If a crisis is to be expected, medi- 
cine is superfluous." 

Some again have imagined that Hippocrates, in his adoption 
of this doctrine, has been influenced by the harmony of num- 
bers, according to the Pythagorean philosophy. In that case 
the irregularity in the changes noticed by Hippocrates would 
not have been admitted, and which Celsus considered as con- 
stituting their inconsistency. Van Swieten very properly urges 
this fact as an evidence of the correctness of Hippocrates, and 
that he has made a faithful record of what he saw in that cli- 
mate. Some, too, suppose the works bearing the name of 
Hippocrates to be written by different hands, and that the doc- 
trine of critical days, with some other doctrines, were not writ- 
ten by the sage. But Dr. Rotheram very properly contends, 
from the uniform style, and the same provincial dialect running 
through those writings, that they are all the production of the 
same hand. 

Among the moderns this subject has received comparatively 
little attention from the practitioner ; for diseases have under- 
gone so much change in their character by climate, by mode 
of life, and especially by the more active treatment that is now 
pursued, compared with that of former days, that they are ne- 
cessarily more irregular in their terminations : whereas, in the 
earlier ages, diseases were seldom interrupted in their progress 
by medicine, and the means employed w r ere comparatively in- 
efficient. Still, however, this tendency in fevers to such critical 
terminations on particular days, is doubtless to a certain extent 

* See lib. iii. cap. 4. 



Divisions and characteristics of fevers. 301 

well founded, and merits attention. We have further evidence 
of the correctness of the observations of Hippocrates, as they 
were made in Greece and Asia Minor, that the same have since 
been confirmed by Cleghorn on the shores of the Mediterranean, 
by Balfour in the East Indies, by Jackson in the West Indies, 
and other writers on the fevers of hot climates. As far as 
they have been attended to in northern latitudes, and in temper- 
ate climates, they have also been verified. The experience of 
Dr. Cullen, Dr. Fordyce, and of Dr. Willan, also concur in the 
support of this doctrine. The periodical movements which 
take place in the human constitution are no less favourable to 
this explanation. If habit governs our appetites, our excretions, 
our hours of sleep, the return of diseases, &c, we ought not to 
be surprised at the tendency to the termination of diseases at 
certain definite periods. The observing physician will at least 
keep them in view, and as far as possible render them subservi- 
ent to his purposes, not only in predicting the event of a dis- 
ease, but in directing his prescriptions to promote a favourable 
termination, or to counteract any unfavourable result that may 
be expected. 

Fevers have been variously divided, first, according to the 
extent to which they spread, as, 

1st. Epidemic, i. e. when diffused through a country — as 
influenza, dysentery, scarlatina, cynanche maligna; that is, 
as connected with a general condition of atmosphere. 

2d. Endemic, circumscribed within certain limits, indepen- 
dently of any general condition of atmosphere. 

Secondly. Fevers have been divided according to their 
causes, as into marsh fevers, contagious fevers. 

Thirdly. According to their character, as it regards their 
symptoms, whether inflammatory, bilious, nervous, putrid or 
malignant. 

And, again, they are divided according to the distinctness of 
their paroxysms, into intermittents, remittents, and continued. 
These are the least ambiguous denominations ; whereas the 
distinctions of putrid or malignant cannot be appropriated to 
any particular form of fever. 

In the nosological arrangement we have adopted, you will find 
that we divide fevers into, 1st. Intermittents — that is, such as 
recur at regular periods, but which also have as regular periods 



302 



LECTURE XXIV. 



of intermission, or perfect apyrexia or total absence of fever. 
2d. Remittents, in which there is a sensible abatement, and 
which return with great regularity, but not amounting to a 
perfect apyrexia or intermission. 3. Continued fevers, which 
have no intermission, nor a regular remission, and are fre- 
quently without even an evident abatement for many days 
together, as typhus, yellow fever, plague, dysentery, &c. 

This distinction, you will perceive, is not admitted by Dr. 
Cullen. On the contrary, intermittent and remittent fevers are 
considered by him as one and the same, because they fre- 
quently run into each other. The same union has been made 
by Wilson; but we might with the same propriety include con- 
tinued fevers under the head of inter mittents, for intermittents 
not unfrequently end in remittents, and then proceed even to 
typhus or the continued form. 

Dr. Cullen remarks, (see note in his Nosology, vol. ii. p. 45,) 
that intermittents and remittents arise from marsh effluvia; 
that they both appear in the same places or situations, and at 
the same season of the year ; that they are equally epidemic, 
and that they are cured by the same means ; that they change 
type in the same person ; and he adds, that for these reasons 
they should not be in different orders, nor even in different 
sections ; but that they should both be included in the same 
section, as modifications of the same disease ! ! Even if all his 
premises were true, while the two diseases differ in their cha- 
racters they should hold a different place in a well-formed noso- 
logical arrangement ; otherwise, let us abandon all nosological 
distinctions. The same reasons, as far as they do apply to 
intermittents and remittents, might be extended to continued 
fevers, and remittent and continued be made one, as they were 
by Vogel. The typhus fever, as it appeared at the Walkill, 
commenced as an intermittent, then become remittent, and 
at length ended in typhus. The same thing has been fre- 
quently observed of the Lake fevers. They commence for the 
most part in an intermittent form, but by their duration they 
become remittent, and at length terminate in typhus. They are 
not originally of the continued form, much less do they assume 
in any stage the character of yellow fever, as stated by certain 
late writers. The malignant Walcheren fever, as described by 
Davis, also frequently commenced under the guise of an inter- 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 303 

mittent. Still, such is the difference of the character in the pro- 
gress and termination of the two diseases, that they should be 
kept separate. 

But Dr. Cullen is not correct in his premises. They do not 
all arise from marsh miasma; he should have qualified his 
definition with a plerumque " miasmate paludum ortte." Even 
intermittents, as I have already observed, do not always arise 
from miasma, but from cold, moisture, debility, and other 
causes. Relapses are especially induced by debility as the 
predisposing cause. Galen observes, that acid drinks will 
bring back intermittents. Debilitating medicines will, in like 
manner, renew an intermittent. A case occurred to me some 
time since, in which venesection, mercury, and other means 
directed for the cure of hepatitis, brought back an intermittent. 
Tartar emetic, given for the cure of croup, to a child who a 
short time before was cured of an intermittent, reproduced that 
disease. I have related to you another case in which mental 
distress revived the paroxysms of an intermittent. Inflamma- 
tory complaints, it is well known, frequently terminate in inter- 
mitting fever ; every practitioner must have witnessed this fact. 
Besides, as I have already observed to you, intermittents have 
been met with in the city of New York at all seasons of the 
year. They cannot therefore be considered as exclusively 
arising from marsh miasma. Remittents in like manner are 
frequently generated in the system, without marsh miasma as 
their cause ; and frequently, too, they run into the continued 
form, becoming typhus. The state of the system, as well as 
the effects of seasons of the year, has I believe considerable 
agency in superadding the remittent character to an intermit- 
tent, as well as the typhus type to the remittent. It will also 
perhaps be induced, when the miasma may exist in greater 
quantity than usual, or when such miasma may be accompa- 
nied with circumstances calculated to debilitate the system ; as 
when miasma may be united with moisture, as at the Walkill, 
or upon draining marshes in general ; especially when the 
causes are combined with great heat of climate, as in the 
southern states. The swamps of North Carolina, we are told 
by Dr. Williamson, were remarkably healthy before the sun 
had access to the surface of the earth. But after the processes 
of clearing and draining, the sun then exhaled the most deadly 



304 LECTURE XXIV. 

vapours. But it is also to be observed, that intemperance and 
the confined cabins of the poor, under such circumstances, also 
give this tendency to the remittent form of fever. Remittents 
on the other hand become intermittents, where the intestinal 
canal is well cleansed, and all irritation from this source has 
been removed, and nothing but miasma or the former habit of 
returning paroxysms remain. Nor are intermittents and re- 
mittents cured by the same means. An emetic, an anodyne 
draught, and the Peruvian bark will cure the one, but not the 
other. Bark and wine in the remittent will be injurious, and 
will frequently convert it into the continued form of fever, by 
the excitement they produce. It is important then, as it re- 
gards distinction of symptoms, to place these diseases under 
different heads, but still more so as to the cure, for we shall 
find very different and even opposite treatment called for, ac- 
cording to the causes producing them. Hence, then, I have 
made three heads. 

I. Intermittents, which I define to be those fevers arising 
for the most part from marsh effluvia, consisting of repeated 
(not many) paroxysms, with a manifest intermission, and re- 
turning with remarkable exacerbations, and in general with 
shivering, most usually but one paroxysm in a day. The first 
of these is, 

1. The quotidian, which has similar paroxysms, returning 
about every twenty-four hours ; and the paroxysms generally 
in the morning, and under sixteen hours' duration. The inter- 
val, as it is improperly called, is considered as embracing 
the whole period of time from the commencement of one 
paroxysm to the commencement of the next. The quotidian, 
it is to be remarked, does not always occur in the morning. 
Dr. Good remarks that intermitting fevers, whether quotidian, 
tertian, or quartan, have their paroxysms recur regularly in the 
day time — the quotidian in the morning, the tertian at noon, 
and the quartan in the afternoon ; and that in no instance do 
the paroxysms take place at night. Dr. Good, with all his abi- 
lities and extraordinary erudition, and although an eminent 
surgeon and poet, has, I suspect, never been particularly con- 
versant with fevers. 

The second form of intermittent is the tertian, in which 
similar paroxysms return about every forty-eight hours. The 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 305 

accessions of the tertian take place, for the most part, at noon, 
and are under ten hours' duration. This is not invariably the 
case. 

A third form of intermittent is the quartan, in which similar 
paroxysms return about every seventy-two hours, and the ac- 
cessions generally in the afternoon, (paroxysm under eight 
hours' duration.) This form of fever is of less frequent occur- 
rence. I have seen but three or four cases in twenty years. 

There are, however, other forms noticed by writers, in which 
the intervals are still longer. Hippocrates notices quintans. 
Van Swieten mentions a quartan being changed to a quintan. 
Burserius quotes twelve physicians who have seen quintans. 
Septans, or septenaries, are also recorded in the books. Boer- 
haave expressly states that he has seen a fever which returned 
every seventh day ; and Burserius quotes nine persons who 
have seen septenaries. Octans I have seen frequently. A case 
occurred in my own family, in the autumn of 1812. My atten- 
tion was first called to this form of intermittent by the elder 
Dr. Bard, who had in his long practice met with it so frequently 
that he was led, in every form of intermittent, to continue the 
bark until the eighth day had passed by, counting from the day 
of the last paroxysm. Burserius refers to sixteen persons who 
have seen octans. Dr. J. Bard went still further ; he has re- 
marked that some fevers he has known to return at the end of 
fifteen days. But all these forms are considered by Dr. Cullen 
as only irregularities of the tertian or quartan periods. For- 
dyce, too, considers them as so many varieties of the tertian 
type ; that they are all tertians in disguise. Nay, he states, as 
you will see in his first dissertation, that all fevers, whether 
continued or intermitting, are but varieties of the tertian type 
of fever ; a doctrine calculated to destroy all distinctions, as 
well as those rules of practice which arise out of them. 

The most usual forms of intermittent are then, 1. Quotidians, 
occurring every twenty-four hours, coming on in the morn- 
ing, and lasting sixteen hours ; 2. Tertians, occurring every 
forty-eight hours, coming on at noon, and lasting ten hours : 
3. Quartans, occurring every seventy-two hours, coming on in 
the afternoon, and lasting eight hours, and generally but one 
paroxysm on the day of the attack. It is also observed by- 
some writers, that the paroxysms do not often occur at night, 
27 



306 LECTURE XXIV, 

alleging as the reason, that they are counteracted by sleep. 
This is not true. In some of the cases already referred to, the 
paroxysms changing their hours of attack, they at length re- 
turned at one, two, and three in the morning, attacking the 
patients when actually asleep; and such is the effect of habit, 
that they as readily recur at these hours as the propensity to 
empty the bladder with those who are accustomed to evacuate 
water at a particular hour. This leads me to remark another 
distinction made by physicians, into anticipating and postpon- 
ing intermittents ; that is, that they regularly return either an 
hour or two earlier or later than the preceding paroxysm. 
They are hence called anticipating quotidians, tertians, or quar- 
tans, postponing, &c. It is important to attend to this fact. It 
aids our prognosis. In the anticipating the disease increases in 
violence. But in the postponing, the disease is becoming less 
violent and is more easily cured. Another distinction of inter- 
mittents is founded upon the number of paroxysms on the day 
of attack. Generally, you will remember, they have but one 
paroxysm on the same day — but in some cases they have more 
— they may have two, or even three paroxysms on the same 
day. A tertian or quartan is then accordingly said to be a 
duplicate or triplicate tertian or quartan. This distinction, 
you will remark, is not applicable to a quotidian ; for where the 
paroxysms recur so frequently it cannot be longer considered 
as an intermittent, but is a remittent, and soon displays the con- 
tinued type.* Tertiana duplicata, Tertiana triplicata ; i. e. hav- 
ing two or three paroxysms on the same day, but none on the 
intermediate. 

Another variety to be noticed, is that in which the parox- 
ysms return daily, but one day the paroxysms are severe, on 
the other mild. These are called, not duplicate, but double ter- 
tians, and double quartans. Tertiana duplex, i. e. the ter- 
tian every other day has similar paroxysms, equally violent ; 
but on the intermediate day the paroxysm is mild and in- 
considerable ; and by this circumstance they are distinguished 
from quotidians. This constitutes the hemitritseus of the 

* But Burserius, in describing his quotidians, gives to some of his varieties 
two or three paroxysms on the same day ; but these are merely continued fevers, 
for the paroxysms are then protracted into each other without an intermission ; 
yet he denominates them simple, double, and triple quotidians. 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 307 

ancients, the semi-tertiana of Cleghorn ; I. e. where the parox- 
ysms (according to their description of them) return daily, but 
where the interval between the first and second paroxysms, 
or rather the remission, is greater than that between the second 
and third ; that again between the third and fourth more con- 
siderably than between the fourth and fifth, &c. There is, 
therefore, I assert, no difference between the semi-tertian and 
double tertian ; for every other day the fit being more violent, 
the intervals between the different paroxysms will necessarily 
be different. In 1812, Dr. Post and myself both saw many 
cases of this double tertian type of intermittcnts. 

Another variety is the tertian a triplex, having two parox- 
ysms on one day, and one on the intermediate, but that a slight 
one. Tulpius goes still further — he gives you a case of a ter- 
tiana quadruplex, in which two paroxysms take place every 
day. What was this but a double quotidian ? Tulpius tells 
us, too, that it supervened upon a double tertian. Lommius 
and Eller describe their hemitriteus as corresponding with the 
tertiana triplex of this day. 

The quartan, too, may be duplex and triplex as well as du- 
plicate and triplicate. Duplicate, you will recollect, signifies 
where two paroxysms occur every fourth day, and none on the 
intermediate days. But quartana duplex signifies that the pa- 
roxysms every fourth day are similar ; i. e. only one paroxysm 
on the fourth day, but that a severe one; yet a slight paroxysm 
occurs on one of the intermediate days ; so that the patient has 
only one interval day. In like manner, we may have quartana 
triplex as well as triplicate. Triplicate, you remember, has 
three paroxysms every fourth day, but none on the intermedi- 
ate days. Quartana triplex has one paroxysm every fourth day 
violent ; but it has a slight paroxysm on both of the intermedi- 
ate days. Intermittents are also said to be subintrant or sub- 
continued ; i. e. where a second paroxysm begins as soon as 
the first is ended ; but in this case there surely cannot be said 
to be an intermission ; it only amounts to a remission, the re- 
currence is so frequent. Quotidians, tertians and quartans, are 
also said to be true and spurious ; they are called true, where 
the paroxysm is completed within twelve hours ; but if pro- 
tracted beyond that period, they are called spurious. The same 
is applied to double tertians, &c. The quotidian and tertian 



308 LECTURE XXIV. 

are also distinguished into universal and partial — universal, 
when the whole system is affected — partial, when it shows 
itself only in a particular part of the body, as the head, (this 
form is of frequent occurrence,) the eye, &c. 

This leads me to notice the arrangement of Alibert, who 
makes many distinctions founded on a particular symptom or 
symptoms ; i. e. the convulsive intermittents ; the hepatic ; the 
choleric, syncopal, &c. Or he divides them according to the 
diseases with which they are associated, as hydrophobic, ca- 
tarrhal, exanthematic, rheumatic, epileptic, &c. I also remark, 
that in some intermittents there is a greater tendency to assume 
the continued type than others. The quotidian are most apt to 
run into the continued form ; the tertian next ; the quartan 
least. Quintans, and the more protracted types, Van Swieten 
remarks, he never knew to be changed into continued fever. 
The question next arises, Why is the quotidian most, and the 
quartan least apt to assume the continued type? In order to 
answer this question it is necessary to observe, that the quoti- 
dian has the shortest cold stage, but the longest hot stage, or 
stage of excitement ; and that the whole paroxysm is longer 
than the other forms of intermittent. That the tertian form has 
a longer cold stage than the quotidian, and a shorter hot stage, 
but that the whole paroxysm is shorter than the quotidian. That 
the quartan has the longest cold stage,* and the shortest hot, 
and that the whole paroxysm is the shortest of the three. The 
quotidian, therefore, having the longest paroxysm of excite- 
ment is most debilitating, for the interval being shorter there is 
less opportunity of giving either medicine or nourishment to 
restore the tone of the system — hence, therefore, the worn 
down solids and vitiated fluids tending to the continued form 
of fever; the system is consequently rendered more excitable 
by the original or additional causes of irritation. A further 
evidence of the correctness of this view is, that when tertians 
or quartans become continued fevers, there is first a reduplica- 
tion of their paroxysms on the intermediate days, assuming the 
quotidian character. In like manner the quotidian becoming 

* Dr. Grant, in his Observations on the Diseases of London, states that he has 
seen the cold stage of the quartan continue fifteen hours. It usually lasts but 
about two hours. Still it is remarked that the feeling of cold is not so severe 
and depressing as that of the tertian, though longer in duration. Hence, too, 
the quartan type is peculiarly severe and dangerous to those advanced in life. 



DIVISIONS AND CHARACTERISTICS OF FEVERS. 309 

continued, its paroxysms are first lengthened into a remittent, 
when the chill is scarcely perceptible ; and in proportion, too, 
as fevers have this tendency, the cold stage diminishes at the 
same time that the hot lengthens ; that is, the system even dur- 
ing the period called apyrexia is under some irritation from the 
accumulation of the cause, or from the state of the system 
itself. Hence there is less chill' and more excitement; and 
when these changes are perceived, and a tendency to the con- 
tinued type appears, let it teach us to be more active in our 
treatment to prevent such fermentation, and to procure longer 
intermissions. In simple tertians and quartans we have a per- 
fect apyrexia, for the system is less debilitated. When there 
is a longer chill there is no additional source of excitement to 
rouse the vessels into immediate reaction, as in quotidians, or 
the double tertians. From the length of the chill, therefore, 
we may be enabled to foretell the nature or type of the inter- 
mittent that is to ensue, whether it be a quotidian, a tertian, or 
a quartan. When, therefore, Galen says a physician should 
know the type of fever from the first paroxysm, he speaks like 
a man of experience and great practical observation. His di- 
rections for ascertaining a quotidian, viz. " when the heat is 
joined with acrimony," indicate the same practical attention to 
the phenomena of disease ; i. e. the vitiated state of the system 
having taken place, Galen tells you that the continued type of 
fever is approaching. The body, he observes, then abounds in 
crude humours. I have also in this city, in the hot season of 
the year, seen in intermittents, especially on the days of attack, 
the most malignant symptoms indicating such deranged state of 
the fluids, but which on the intermediate days were relatively 
removed by a profuse perspiration, which took place in such 
paroxysms. I am therefore not surprised at the malignancy 
attached to intermittents by Cleghorn and other writers, who 
have witnessed their character as influenced by a hot climate. 
It is also observed by all practical writers, that vernal inter- 
mittents are less apt to become continued, and autumnal most 
so. This fact may be explained from the septic state of body, 
and other circumstances of season, state of the atmosphere, 
decomposition of animal and vegetable matters which occur in 
autumn, but not in the spring. Such are the observations we 
have to make on the character of intermittents. 
27* 



310 



LECTURE XXV. 



TREATMENT OF INTERMITTENTS. 



The treatment of intermittents which is now to be attended to, 
may be divided into the treatment proper to be pursued during 
the paroxysm; and the means to be made use of in the inter- 
mission, to prevent its return. The remedies proper to be ad- 
ministered in the invasion of fever in general, or the cold stage, 
those proper during the state of excitement, or the hot stage, and 
those called for in the succeeding stage, have already been very 
fully noticed. The same indeed, which were then pointed out, 
are no less applicable in the treatment of the different stages of 
intermittents — as for example, our object is in the first stage, to 
quiet the irritation of the nervous system by means of opiates, 
warm bathing and warm drinks. To reduce the excitement of 
the arterial system which succeeds, by the different evacuations, 
which have been pointed out, according as the one or the other 
may be necessary; and by various tonics and stimulant nourish- 
ment to supply the loss of strength that may have been induced 
when the sweating stage has taken place, and the febrile excite- 
ment has subdued. On these subjects, therefore, I need not now 
detain you. I may, however, remark that, both in the treat- 
ment of intermittents and remittents, when you may be called 
upon during the paroxysm, you will administer very much to 
the comfort of the patient, by the exhibition of opiates, and that 
too, not only in the cold fit, but oftentimes also in the hot stage,* 

* It is a common opinion," says Lind, " that the cold fit is attended with the 
greatest danger, and that most who die of intermittent fevers expire during the 



TREATMENT OF INTERMITTENTS. 311 

with the exceptions already pointed out, as in great fulness of habit, 
or an inordinate determination to particular parts of the body, as to 
the head or chest ; but, under the usual irritations which we meet 
with in intermittents and in remittents, we administer opiates with 
the best effects in the hot as well as in the cold stage. They dimin- 
ish the rapidity of the circulation, they usually promote dia- 
phoresis, they correct and lessen the heat, which is itself a source 
of great irritation, and they in all respects, compose the feelings 
of the patient ; they allay pain, they remove the anxiety and 
oppression which patients frequently suffer during the paroxysms 
of fever. They invariably shorten the paroxysm, and never 
augment its violence. Opium may be given if the stomach be much 
disturbed, in weak mint water, as its vehicle, or in case of much 
heat and excitement, the combination before mentioned, with sp. 
mind, is to be preferred, or the Dover's powder, grs. x. In a 
quartan of two years' standing, in St. Thomas' Hospital, Dr. 
Fordyce successfully prescribed a full dose of Dover's powder, 
with a sweating draught of the carbonate of ammonia two hours 
before the fit — the bark afterwards effected the cure. Dr. Lind, 
who was the first to introduce this practice, of administering opi- 
ates in intermittents, and which he did as early as 1766,t always 
considered them useful by shortening the paroxysms, and thereby 
bringing on an intermission. This fact is no less favourable to 
the doctrine, that irritation constitutes the proximate cause of 
fever. In cases of costiveness, it was his practice to blend a ca- 
thartic with his opiate ; that after the opium had produced its 
effect, the cathartic might leave the bowels in such a state that he 
might immediately after avail himself of the opportunity of ad- 
ministering the bark. This, inahot climate, became doubly neces- 
sary. The cathartic which Dr. Lind usually blended with the 
anodyne, was the tinct. sacrae. §ij.; but under other circum- 
stances, his opiate draught was as follows : xv. to xx. drops lauda- 



rigors. I never saw a person die in the cold fit, but have known several carried 
off in the hot one, by strong convulsions, delirium and other symptoms ; and am 
clearly of opinion, that it is the hot fit or fever, which most endangers the pa- 
tient's life, and by its continuance, weakens and impairs his whole habit of 
body. In old age, the cold stage is most dangerous. — See Lind, p. 318. 

tHot climates, p. 318, 322, 323. 



312 



LECTURE XXV. 



num; 5ij. syrup of meconium; 31J alexiter spirit : ?ss. aq. font. 
This was his draught in the hot fit. 

The next indication, therefore, is to prevent the recurrence of 
the paroxysm. The first means of effecting this object, is to avoid 
the remote causes ; to prevent the exciting cause from operating 
on the system, (that is, as far as that cause may depend upon ex- 
ternal circumstances.) With this view let your patient get out of 
the way of it, by avoiding the air; if in marshy and moist situa- 
tions, let your patient be removed to elevated grounds, to a dry 
and sandy soil. In like manner, let him go from the interior 
country to the air of the sea shore. Lind, (page 313,) speaking of 
the effects of sea air, observes, that this change of atmosphere is 
" one of the most effectual means of obtaining a cure ;" and adds 
" that the most obstinate intermittents he ever had seen, were 
thus cured" — that they did not experience a single fit after 
they were on board ship. In like manner, a little daughter 
of mine was thus cured of an obstinate quotidian by means of sea 
air. I took her to Long Branch after being much reduced by it; 
she had not a single paroxysm more, but returned in three or four 
days perfectly restored. I have known persons from Duchess 
county, members of Dr. Bard's family, where they were under 
the influence of an obstinate intermittent, to come to the city. And 
when the city is unhealthy, I frequently send my patients to the 
country, especially to places where the situation is elevated and 
dry. It is, however, more frequently my common practice to 
send children, with whom it is always more difficult to cure the 
disease by other means, to the sea shore, to Staten Island, and 
situations where they experience the sea breeze before it is much 
mixed with the land air. It is another proof, besides those I have 
already mentioned, that the salt atmosphere extends beyond the 
spray of the sea, that intermittents very rarely occur, even 
within some miles of the sea shore. In the treatment of remit- 
tents this stimulant effect of sea air is no less manifest; its stimu- 
lant effects are also very apparent in other diseases — as in per- 
tussis, chronic catarrh, bowel complaints of children, which in- 
deed I consider to be the remittent in disguise — the infantile re- 
mitting fever of Dr. Mann. — (See his Prize Dissertation.) 

Secondly: When the poison is in the system, when the habitual 
recurrence of the fever is established, and the hour of its return 
is ascertained, our object is still to prevent the system from suffer- 



TREATMENT OF INTERMITTENTS. 313 

ing a return of the paroxysm. For this purpose, we have vari- 
ous resources : we may diminish the sensibility of the system to 
its action. This may be done, 1st by opium, administering it, 
say two hours before the fit is expected to return. But with this 
view it must be recollected, that a larger dose is necessary to 
counteract the irritation attendant on the paroxysm of this dis- 
ease, than is exhibited under ordinary circumstances : from 50 
to 100 drops should be given to an adult to obtain its full effects. 
It should also be exhibited in some agreeable vehicle, lest it be 
rejected from the now irritable stomach. The patient, too, should 
remain in bed, and in a perfectly quiet and a dark room ; its ope- 
ration should also be aided by some tepid drinks, to secure its 
effect upon the extreme vessels, as a cup of catnip, or some other 
herb tea, or wine whey. It is a good general rule with regard to 
all medicines, that the patient should not know the medicine he 
is taking; in the present case, particularly, if the patient should 
neither know the medicine nor the dose he takes. The same pre- 
caution is necessary in administering arsenic, otherwise his preju- 
dices and his anxiety will counteract the effects we intend it to 
produce. Laudanum too, is preferable to opium, as it is quicker 
in its operation ; but another form, to secure its febrifuge effects, 
especially upon the surface, is to blend it with aq. ammon., say 
thirty drops aq. ammon. with from fifty to sixty or eighty 
drops of laudanum. This combined, I have found much more 
effectual than the laudanum alone. 2d. Put the system under 
a new and stronger irritation than the operating cause. " Every 
means/' says Dr. Blane, " of inducing a powerful excitement 
in the principal functions of the body, at the period of attack, 
seems to possess a power of preventing it." Bisset, in his 
Medical Constitution of Great Britain, recommends the vol. 
alkali to be given, in doses of xv. or xx. drops every hour. 
Various vinous or spirituous drinks are also recommended. Spiced 
wine whey, ffej. before the paroxysm, covering the patient warm 
in bed ; cider, made hot with ginger, and taken off too as hot as it 
can be swallowed. Rum, brandy, gin, whiskey, and usquebaugh, 
(the celebrated Irish potation, which is distilled with cloves or 
other spices,) are all prescribed as sovereign cures, or rather pre- 
ventives of the paroxysm of an intermittent. It is surprising 
too, the quantity that the system will bear under the irritation of 
this disease, and indeed, which under other circumstances would 



314 



LECTURE XXV. 



destroy life. A half pint of rum, brandy or gin, medicated 
toddy, with the addition of a tea-spoon full of pepper, or highly 
spiced with nutmeg, (a whole nutmeg is taken at a dose on these 
occasions,) grated into it, or other aromatics, is a common pre- 
scription to prevent the fit of an intermittent. I knew in 
one instance, a bottle of brandy to be taken off with this view; 
it cured the disease, but the man w r as deranged while under the 
influence of the remedy. Some again, have recourse to various 
other stimuli, as the spirits of turpentine, a table-spoonful before 
the fit; the juice of rue or of groundsel, a pint of the infusion of 
horse-radish, ^oz. of mustard seed in half a pint of gin as its 
vehicle, three mornings successively, or a large dose of capsicum, 
as recommended by Collins, Med. Com. vol. ii. Indeed, there 
are hundreds of prescriptions of this kind that are employed in 
this way ;* but they all resolve themselves into the same princi- 
ple, that of exciting a new and stronger irritation, which destroys 
or counteracts that of the disease. With the same view, porter 
has also been taken with the best effects, to prevent the paroxysm 
of an intermittent. 

In 1779 or 1780, after suffering a very tedious intermittent, 
for it resisted all the means that were then usually prescribed as 
bark, the infusion of lign. vit, &c, I had recourse to a bottle of 
porter, as directed to me by a sea-captain. In 1784 or 17S5, I 
had an attack of the same disease when at the academy of Hacken- 
sack, and was cured in the same manner. Lind throws out the 
idea, that some particles of arsenic may exist in the glass, which 
are given out when ignited, and are thus conveyed in the beer. This 
is improbable and unnecessary. Arsenic is not so immediate in its 
effects, but requires three or four days. At all events, porter is one of 
the best auxiliaries that can be made use of in the cure of inter- 
mittents. 

The practice of bathing, also deserves our notice — that of im- 
mersing the patient in a hot bath, both before and during the in- 
vasion, and keeping him in it until the fit passes over ; for this pur- 
pose, the bath should be heated to 96° or 98° at least, and you will 
also add to the stimulating effect of the bath by administering to 
your patient at the same time, a bowl of wine whey. 



* See Lind, p. 313, where indeed you will see a catalogue that will surprise 
and amuse you. 



TREATMENT OF INTERMITTENTS. 315 

I have also made use of a cold bath with similar good effects, 
administering it a short time before the paroxysm is expected to 
return. Applied in the form of a shower-bath is the most pow- 
erful mode of applying it. Or, in case of a young subject, let 
him stand in a large tub, and a pail of cold water be suddenly 
poured over him a short time before the fit is expected to return. 
This secures the stimulant effects of cold. In this way, in the 
autumn of 1S11, I cured one of my sons, and other children in 
the same family in which I resided, in the neighbourhood of this 
city. But, as I have formerly observed, the effects of cold water, 
as the means of preventing the return of intermittents, depend 
both upon the state of body in which it is applied, and the man- 
ner of its application. It is, accordingly, a fact well ascertained, 
that at the sea-shore, both at Long Branch and Rockaway, it fre- 
quently happens that persons who go in to bathe, bring back the 
disease, although they may have been freed from it by residing at 
the shore. Yet omitting the bath, and continuing to respire the 
sea-air, they would soon escape the disease, and rapidly recover 
their strength. The solution of the fact is this: that many per- 
sons go there very much debilitated. The heat generating power 
being reduced, the cold-bath, especially when applied by immer- 
sion, and the patient perhaps remaining in the water a considera- 
ble length of time, debilitates him by carrying off his caloric : 
whereas, the salt air, exciting the system, and improving the ap- 
petite, immediately counteracts the return of the disease. But 
if the person using the bath be not greatly weakened, and sud- 
denly plunges into the bath without remaining in it, in that case 
its stimulant and beneficial effects will be secured to the patient. 
Its operation, therefore, depends both on the condition of body 
and the suddenness and duration of the cold that may be applied. 
The stimulus of exercise, as fast walking, running, or riding on 
horseback, a short time before, or when the fit is expected, has 
prevented the return of the paroxysm. The remedy as recom- 
mended by Asclepiades, of putting his patient on horseback to 
open the pores that are obstructed, is perhaps now admissible. 
Upon the same principle, powerful stimuli, applied to the more 
sensible parts of the body, have been found useful. Blisters, 
applied six or eight hours before the paroxysm, to the inside 
of the arms, thighs, wrists, or ankles, are remedies of great 
efficacy; or stimulating plasters — as the celebrated frankincence 



316 LECTURE XXV. 

plaster, which is prepared as follows : Thuris, gij.; tacamahaca, 
3i.; croci, gr. x. ; terebinth Venetae, q. s. Mesceantur ut fiat 
emplastrum carpis applicandum. (See Lind, 312.) 

2d. Plasters of Burgundy pitch, either alone or combined 
with a proportion of blistering ointment, say one-eighth, or one- 
tenth, constituting the emplastrum calidum. Or, 

3d. Lind recommends, among other applications, common salt, 
beat up with the whites of eggs, (Lind, 312,) to be applied to 
the wrists or ankles. 

4th. Garlick, beat up with hog's-lard, is applied with the 
same intention, either to the wrists, or as sinapisms to the soles 
of the feet, or rubbed upon the spine. 

5th. The oleum succini, oil of amber, is also made use of, and 
is among the best of the external applications. This may be ap- 
plied to the wrists, or it may be made use of by anointing the 
spine with it. 

6th. Among other stimuli, made use of to prevent the return of 
the paroxysm, is directly exciting the heart and larger vessels, by 
arresting the flow of blood into the extremities, generally one of 
the upper and one of the lower, by means of tourniquets. This 
remedy was, I believe, first recommended by Mr. Kelly. You 
will see an account of it in the 2d vol. of the Annals of Medicine. 
To produce this effect, it is directed to be applied from ten to fif- 
teen minutes either before or during the cold fit But we have 
yet another resource, that of impressing the nervous system 
through the medium of the mind — calling into operation the 
principle of faith — and which Dr. Rush introduces almost as a 
distinct faculty of the mind. It is upon this principle, probably, 
that the celebrated amulets (abracadabras) and little bags suspend- 
ed about the neck, containing a few grains of camphor and saf- 
fron, operate in counteracting the nervous irritation constituting 
the habitual return of fever. And with all deference to the 
learned gentlemen of the great metropolis, who have been of late 
so earnestly engaged in the discussion of the principles upon 
which this disease is cured by the late fashionable prescription 
of sourbugs, bruised spiders, cobwebs, gr. x., and the snuff of a 
candle, I believe we must seek for the solution in their operation 
through the medium of the strong mental impression which these 
disgusting substances are calculated to produce. Shakspeare's 
cauldron of the witches exhibited to Macbeth, is not made up 



TREATMENT OF INTE11MITTENTS. 317 

of more strange and terrific materials than are exhibited in this 
disease. His cauldron, you know, is made up of 

" Root of hemlock, dig'd in the dark ; 
Maw and gulf of salt sea shark ; 
Toad, that under the cold stone, 
Days and nights has thirty-one ; 
Eye of newt — toe of frog ; 
Wool of bat, and tongue of dog ; 
Adder's fork, and blind worm's sting ; 
Lizard's leg, and howlet's wing." 

In ours, 

The herb of wormwood, dried in the dark ; 

Wool of hat ; 

Juice of rue — snuff of candle ; 

Spider's web, and crawling bug — 

" Make our charm of powerful trouble. '' 

But although the various stimuli, we have enumerated, fre- 
quently prevent the return of the paroxysm, we are sometimes 
disappointed. I have even known, in the case of a quotidian, an 
abscess to form of considerable size, and to be opened on the 
morning of the fit, and yet that irritation was not sufficient to 
prevent the return of the fit! Whether we succeed or not, it 
will be proper, in the interval of fever, to administer the more 
permanent stimuli, or some medicines, as provided for in the third 
indication, which is, 

3d. To produce a permanent state of excitement, and to di- 
minish the sensibility of the system by tonics. By tonics are 
not meant diffusible stimuli, which are indicated in cases of sud- 
den exhaustion of the nervous system; but such remedies as are 
calculated to make more durable impression upon the whole sys- 
tem, and at the same time to give vigour to the muscular as well 
as the nervous fibre. Diffusible stimuli are addressed more espe- 
cially to the nervous system. Tonics, or permanent stimuli, to 
the muscular as well as the nervous system; i. e. to the circulating, 
the exhalent and absorbent vessels, as well as the organs of volun- 
tary motion. Tonics are also distinguished by their not being 
followed by the depression that most usually succeeds to the dif- 
fusible stimuli. The impression of tonics is more slow and grad- 
ual, while that of stimulants is quick, but transient. Tonics, when 
28 



318 LECTURE XXV. 

long continued, we know lose their effect, and become inert, but 
they do not leave debility behind them. 

Their effects are, 

1st. To excite the nerves of the stomach; to promote the ap- 
petite; to increase the secretions of the stomach; to improve their 
quality, as well as to increase their quantity ; to quicken the solu- 
tion of the food; to promote the peristaltic motion of the whole 
intestinal canal ; accordingly we find some persons incapable of 
digestion, or of performing other functions of the intestines, 
without their use. With this view, a patient of mine who labours 
under a dyspeptic stomach, cannot digest her food without taking 
her habitual dose of bitters an hour or two after eating. Others 
I know who are in the habit of taking a dose of bark daily, as a 
cathartic. 

2d. Their operation is to excite the lacteal system. 

3d. To promote the action of the heart and arteries ; and, 

4th. Of those tonics which are not astringent, to excite the 
excretions, as we see in the effects of iron in promoting the men- 
strual discharge; but, not so with bark, except in cases of extreme 
debility. 

5th. Tonics also have the effect of exciting and contracting the 
exhalent vessels when relaxed by debility, as in cases of exces- 
sive menstruation, or an inordinate excretion by sweat. 

6th. They promote the action of the absorbents. With this 
view we prescribe iron and bitters in that form of dropsy whicli 
succeeds to long continued fevers and other diseases. 

7th. They operate upon the nerves throughout the system by 
quickening their power of action; and, 

8th. They also, probably, operate through the medium of the 
fluids, as well as by the nerves, upon every part of our frame. 
This is especially rendered probable by some of the late experi- 
ments of Sir Everard Home, showing the action of various sub- 
stances through this medium of communication. 

The medicines prescribed with this view to their permanent to- 
nic operation, are of various kinds. They are of two classes, viz. 
vegetable and mineral tonics. Of the first class are Bitters. These 
again are divided into, 

1. Such bitters as are pure; i. e. as containing the bitter prin- 
ple, unaccompanied either by aromatic or astringent matter; 
for it is now ascertained, as you will see by consulting Thomp- 



TREATMENT OF INTERMITTENTS. 319 

son, that there are certain plants which possess this exclusive cha- 
racter, and are hence denominated pure bitters. 

2d. There are bitters which possess, in addition to this bitter 
principle, more or less of an aromatic quality, residing in an 
essential oil, which the plants referred to contain ; and, 

3d. There is another description of bitters which are blended 
with an astringent matter, or tannin, as it is now denominated. 
The plants which fall under the head of pure bitters, and which 
are in most general use, on account of their tonic qualities, are, 

1. The marrubium vulgare, or horehound of the class of plants 
called in the Linnean system, didynamia, gymniospermia. Natu- 
ral order, verticillatae. The whole herb is made use of in infu- 
sion — to be taken cold — an excellent tonic, not only to the stom- 
ach but the whole system. Hence, too, it has come into general 
use in chronic catarrh; not that it possesses any specific effects 
upon the lungs. 

2. Tanacetum vulgare, or tansy. CI. syngenesia. Ord. polyga- 
mia superflua. Herb and flowers, used as a tonic in intermit- 
tent fevers, and as a vermifuge. 

3. Ruta graveolens — rue. 

4. Eupatorium perfoliatum; is also used as a domestic bitter, 
and certainly with excellent effects. 

5. Artemisia absenthium. 

6. Anthemis nobilis — chamomile. Possesses the same proper- 
ties. A small quantity of essential oil, sold in the shops — useful 
in a voyage — in small compass, yet powerful. Useful in diseases 
of the stomach, but less active in diseases of the whole system. 
The cold infusion preferable. A tea- cupful of the flowers — boil- 
ing water, ffeij. when cold, ad libitum. But the most powerful 
are the three following. 

7. Gentiana lutea — root. Infusion with orange-peel. Tinct. 
compos. Tinctura amara.* A grateful bitter, with orange-peel. 
It is a basis of the infusum amarum. 

8. Quassia amara, or excelsa. 

Colomba plant, not much esteemed ; is supposed by Professor 
Willdenow to be a species of Bryonia. Formerly said to be 



* Its composition. — Rad. gentian, ^xij. ; cort. aurant, §vj. ; canell. alb. gij. ; 
coccinell, gss.; boiling water, ifei., digest one day. Brandy, ibxv. Digest seven 
days, or filter. 



320 LECTURE XXV. 

brought from Ceylon, but lately found to be the produce of South- 
ern Africa; and is a great article of trade with the Portuguese 
at Mosambique, in the province of Tranquebar. Aromatic smell; 
bitter taste; powerful and grateful stomachic. 

Infusion — Columbo, gij.; quassia, 3ij. — orange-peel, 5i.; rhu- 
barb, 9i. ; soda, 3ss.; water, fjjiss. — boil to ffci. — strain — take cold. 

2d. Bitters, with aromatics, uniting the stimulant and tonic 
qualities. 

1. Dorstenia contrayerva, commonly used like serpentaria, as 
a stimulant in typhus, gr. v. to 9i. — it has fallen into disuse. 

2. Aristolochia serpentaria, Virginia snakeroot. It is a stimu- 
lant, formerly much used in the typhoid type of fevers. Diapho- 
retic and tonic. 

3. Citrus aurantium, the orange and Cit. medica, lemon, usually 
combined with the purer bitters. An ingredient in the bitter in- 
fusion of the shops. 

The 3d class of tonics, now to be noticed, are bitters, blended 
with the astringent principle that is in combination with tannin. 
I may just remind you, that there are certain tests by which the 
presence of such astringent principle is ascertained. The prin- 
cipal are the following. 

1st. Astringents strike a dark purple or black colour, when 
acted upon by the salts of iron. 

2d. They possess the property of corrugating the animal fibre, 
as is evident when they are applied to the tongue ; and 

3d. Some of the most powerful astringents show the presence 
of the peculiar acid called the gallic acid, or that kind which is 
obtained from galls ; these are the produce of an insect, and as 
their place of growth is the bark of the oak, which is remarkable 
for its astringency, this acid, and the astringent principle, have 
been considered as one and the same thing. It was also discovered 
that the gallic acid in connection with the salts of iron, strike a 
dark colour. This circumstance afforded still stronger evidence 
that the gallic acid constitutes the astringent principle. But it 
has been ascertained that the acid alone possesses very little of 
this astringent quality, and that it is scarcely perceptible ; that 
the colour is not so dark as that created by astringents; and still 
further, it has been found that some of the most powerful astrin- 
gents are wholly destitute of the gallic acid, as the gum kino and 
catechu. 



TREATMENT OF INTERMITTENTS. .321 

Seguin has discovered that the astringent principle is consti- 
tuted by a totally different material. He has ascertained that by 
mixing gelatin with an infusion of the substance containing the 
astringent principle, a precipitation takes place, containing the 
astringency, and leaving the liquor above altogether destitute of 
it. To this precipitate he has given the very appropriate name of 
tannin, so called, from the great application which is made of it 
for the purpose of tanning leather. And in this he has made a 
discovery of very great importance, particularly in that art, for 
by this process of concentrating the astringent matter by means 
of gelatin, leather may be tanned in fewer weeks than it formerly 
took months, and thereby an immense capital saved. 

The process consists simply of adding a quantity of fish glue 
to the vat containing the bark, in a state of infusion ; the astringent 
matter instantly falls to the bottom, where it is brought imme- 
diately in contact with the hides to be tanned, whereas by the 
former process it required a great length of time, at least eight or 
ten months, to produce that change which is now effected in the 
course of six weeks. 

The most important of the class of tonics possessing that astrin- 
cy in connection with its other properties, is the Peruvian bark, 
or cinchona officinalis. It was introduced into Europe in 1632. 
There are at least twenty-five varieties of cinchona well known, 
besides the recent additions made by Humboldt and Bonpland. 

The cinchona officinalis, or Peruvian bark, is the produce of 
different plants. They all, however, belong to the class, Pentan- 
dria, order, Monogynia, and to the same genus. It is the growth 
of South America. There are three kinds of it used commonly 
for medicinal purposes, viz : the cinchona lancifolia, (the pale,) 
the cinchona cordifolia, (the yellow,) and the cinchona oblongi- 
folia, (the red.) The pale comes in small quilled twigs, and thin. 
The yellow in flat pieces, and the red in large flat, thick frag- 
ments. And they vary in colour as their English names indi- 
cate. Of these three kinds, the pale is the least powerful, and the 
yellow the most. But the red is the least offensive to the taste. 
The yellow is so intensely bitter, that it is apt to nauseate. But 
as it is the most efficacious, and more readily yields its bitter and 
astringent principles to both alcohol and water, than the others, 
and as the red bark is so very frequently adulterated, and withal 
is so expensive, the yellow bark is generally preferred in prac- 
28* 



322 LECTURE XXV. 

tice. The yellow is said to be the genuine, original febrifuge of 
Spanish America. 

Before you give the bark, take care thoroughly to cleanse the 
stomach and bowels, and freely to open the skin. This is highly 
important. In hot climates, it is often necessary to administer 
the bark before the apyrexia : there is no time to lose. But in 
our climate, it is proper to wait for the entire solution of the 
paroxysm. It should be given soon after the apyrexia has taken 
place, and discontinued some time before the expected cold fit, 
otherwise its administration will aggravate the succeeding parox- 
ysm. It is not safe or proper to give it when there is any visce- 
ral obstruction, or a strong tendency to local inflammation. 

The most effectual mode of giving the bark, is in substance, 
in doses of ^ss. to 3i. (i. e. about a tea-spoonful) every two 
or three hours. To give less is to trifle with a valuable remedy, 
Lime juice is a convenient and agreeable addition to it. The 
following is an excellent form : R. cinchon. ^i. ; succ. limon. 5i.; 
elixir paregoric, 3\j.; aq. com. §viij. M. This quantity will 
make eight doses ; or it may be given in milk, in coffee, or in 
wine, being rubbed up into a paste. It is sometimes given in the 
shape of an electuary, thus : R. cinchon. pulv. §i. ; super-tart, 
potass. §i. ; carioph. aromat. gij. ; syrup, q. s. M. A very good 
way of exhibiting the bark in substance, is to wrap up the dose 
in a large wafer, made of a paste composed of two teaspoonsful 
of wheat flour in a teacupful of water, and passed between two 
hot irons well waxed. Let the wafer be moistened with a little 
wine, and then folded over the powder. It will then readily pass 
down as a bolus, especially if taken in a" spoonful of wine*. In this 
way, this nauseous article will be retained upon the stomach, 
which will reject it in every other shape. 

The bark may also be given in infusion. R. cort. cinchon. 
5i. ; magnesias calcin. 3i.; aq. pluv. distillat. 5x. filter. This 
is to be taken cold, as when warm it is offensive and nauseating, 
and lime juice may be added to it with advantage. I do not 
think this mode of administration very efficacious, though in some 
cases it may be the best you can adopt. But generally it cannot 
be depended upon in intermittents. 

Next to the actual substance, the decoction has been long found 
the best mode of giving bark. In making the decoction care 
should be taken to boil it in a close vessel, and but a short time, 



TREATMENT OF INTERMITTEXTS. 323 

otherwise you evaporate its virtues, and destroy its strength. 
The decoction should he made with one ounce of the bark to a 
pint of boiling water ; and of this from two to four ounces should 
be given at a dose. To this, the serpentaria, (gij, to the above,) 
may be added, especially if the stomach be very irritable, and the 
patient has some remnant of fever, and is much debilitated. 

Another mode of giving bark is the tincture ; and this is an 
elegant, and often a very powerful, prescription. Huxham's tinc- 
ture is the best form. I frequently have given it alone, and some- 
times in the infusion or decoction. Indeed, in the summer sea- 
son, it is very frequently necessary to add the tincture to the 
watery preparations. 

The bark may be given in extract, in doses of from five to 
fifteen grains. But this is a very uncertain form, as it is rarely 
properly prepared. The heat injudiciously applied in the phar- 
maceutical operation, frequently drives off or destroys all the vir- 
tues of the article. 

You may find it necessary sometimes, when the stomach will 
retain nothing, to resort to the administration of the bark by ene- 
ma. In this way it may be thrown up with milk ; or the follow- 
ing form may be used every four or six hours. Take of the pow- 
dered bark ^ss.; laudanum 3L; starch ^ij. M. After the first 
injection, thirty drops of laudanum will be sufficient ; and for 
young children, ten drops will be quite enough to produce the 
torpor of the bowels necessary to retain the injection. 

I have sometimes, and with great advantage, applied the bark 
externally, by means of the bark waistcoat, the endermic method, 
as it is called in modern phrase. With children especially, this 
may be used with benefit, w T hen it is found impossible to make 
them swallow any thing. 

I have mentioned these different modes of administering the 
bark, because you may sometimes find it necessary to resort to 
them, and may be placed in situations in which you can do 
nothing else. But they have all been superseded, to a great ex- 
tent, by the quinine, a preparation introduced some years ago. 
containing all the essential virtue of the crude material, with- 
out its disadvantages. It has been said that there are cases which 
the sulphate of quinine will not cure so readily as the substance 
itself. But its efficacy, under the circumstances in which the 
bark in other forms is indicated, is now well established. It may 



324 LECTURE XXV. 

be given in pill, in doses of one or two grains, three or four 
times a-day. It may be given in solution. I have generally used 
the following formula: R. sulph. quin. 9i.; elixir vitriol, 3^ j 
syrup of ginger ^ij. M. A tea-spoonful every hour, or every 
two hours during the apyrexia. Or it may be given by enema. 
Children will seldom swallow the pills, and will frequently refuse 
the solution. The extreme bitterness of quinine will revolt them. 
You must then resort to the injection. Dissolve four grains of 
the quinine in three or four ounces of water, and add to it eight 
or ten drops of laudanum, and administer it. 

From some curious experiments very recently made in France, 
it would appear that quinine applied in the endermic mode, 
that is, externally applied, is very efficacious in curing intermit- 
tents. I have no experience whatever as to its virtue in this way. 
But it is said that quinine rubbed up with cerate, and applied to 
a blistered surface, is productive of very striking curative power. 
It is even said that it manifests its activity, when thus used, in a 
few minutes. Should further experiments verify these assertions, 
it certainly will be an invaluable remedy, because sometimes it 
cannot be taken internally, except with great difficulty ; and in 
some cases, as for instance when there is a strong tendency to 
local determinations, and perhaps a disposition to gastric and in- 
testinal inflammation, it cannot be internally administered with 
safety. But from what I can judge of the experiments which 
have been thus made with it, it does by no means appear very 
clear, that the quinine effected the cures. In all the instances, I 
believe, blood-letting was first resorted to. But still it is worthy 
of a trial. 

Sometimes you may find it best to give the quinine in con> 
paratively small doses frequently repeated. There is, I have 
found, frequently an advantage in this. But generally the best 
way is to begin with large doses, to be given at more distant in- 
tervals, so as to produce a strong impression at once. Even eight 
or ten grains have been given at a dose, and the Italian physicians 
give even more. But their fevers require very decided and 
peculiar treatment. 

The introduction of the quinine is an invaluable acquisition in 
the practice of medicine. Combining as it does all the curative 
properties of the bark, it has the vast advantage over every other 
form of it, that it may be given in such small bulk. 



TREATMENT OF INTEEMITTENTS. 325 

A variety of other vegetable tonics, most of them of the cin- 
chona family, have been recommended as substitutes for Peruvian 
bark, such as the cinchona carribsea, the cinchona floribunda, (St. 
Lucie bark,) the cusparia febrifuga, (called by Humboldt, the 
Bonplandia trifoliata,) the Swietenia febrifuga, and the Swietenia 
mahogani. But they are all greatly inferior to the Peruvian bark. 
I, therefore, shall not dwell upon them. You may learn their 
properties from the books ; and the Professor of Materia Medica 
will tell you how they are to be administered, and what they are 
respectively worth. I have, myself, no very great confidence in 
any of them. 

Certain mineral tonics have been recommended for the cure of 
intermittents. The chief of these are arsenic and iron in various 
forms. 

Of the arsenic, Fowler's solution is the best : this is made by 
dissolving sixty -four grains of the white oxide of arsenic in §xvi. 
of water, and adding to it sixty-four grains of the sub-carbonate 
of potash, and Jss. of sp. lavend. compos. It is given in doses of 
from two to five drops, three times a-day, gradually increased to 
eight or ten drops. But, although I know it will cure intermit- 
tents, I cannot recommend it to you. It is a very dangerous 
remedy ; and often leaves consequences far more formidable than 
any ague. A liability to rheumatism, most distressing derange- 
ments of the digestive organs, violent headaches, wonderful ema- 
ciation, and not unfrequently, unmanageable dropsies, are the sad 
consequences of its use. Indeed, for months and years, patients 
who have taken arsenic for the cure of fevers, suffer serious injury 
to health. Never use it, unless the disease should resist other 
means, or you should be placed in situations where none others 
are at your command. 

Iron is far the safest of the mineral articles used in fevers. It 
is given in filings, in doses of from five to ten grains; in the form 
of carbonate, or rust, in doses of from five to fifteen grains ; in 
the form of the sulphate, in doses of from one to five grains ; in 
the shape of the muriated tincture, from ten to fifteen drops in 
wine, water, or syrup. But the best form of iron, and the one 
now most in use, is the Prussiate, (Prussian blue.) It is highly 
valued by some practitioners, and I have seen very good effects 
from it. It may be given in doses of from five to ten grains, 
gradually increased, three times a-day. Its being an inoffensive 



326 LECTURE XXV. 

article, and its being a very cheap one, are its chief recommenda- 
tions. On this account it is very well adapted for use in large 
public institutions, where economy is required. I have used it a 
great deal in the New York Hospital, and have not been disap- 
pointed in it. 

But with the quinine at your command, you need not resort to 
the use of any thing else, unless in some few cases, where some 
peculiarity in the disease, the patient, or the circumstances, may 
demand a preference for some other article. 

I must remark that while you are thus building up the system, 
you must pay great attention to the diet and regimen of your pa- 
tient. Improprieties in these particulars, will counteract all that 
you are doing by remedial means. I need not dwell on these 
points, as I have already spoken upon them so fully. I merely 
remark in conclusion, that a judicious physician will never lose 
sight for a moment of the great importance of a vigilant regard to 
what his patient eats, and drinks, and does. There is nothing, 
however seemingly small, which has reference to these matters, 
that ought to be considered unimportant, or even of trifling mo- 
ment. 



327 



LECTURE XXVI. 



REMITTENT FEVERS. 



Remittent fevers next come under our view. I have already 
remarked that remittents have been very improperly considered 
by many writers, and especially by Dr. Cullen, and by Dr. Philip 
Wilson, as well as by Fordyce, to be mere modifications of the 
intermittent type of fever—whereas, remittents differ from inter- 
mittents in many particulars. These are worthy your regard, 
especially as they lead us to adopt a different and more active 
treatment for their removal. 

In the first place, I remark the remittent fever has not the dis- 
tinct visible rigours and long cold stage that announce the inter- 
mittent form of fever. 

2. The remittent has a much longer hot stage. 

3. The sweating stage is inconsiderable and partial, and is fre- 
quently wanting altogether in the remittent. 

4. In remittents there is no perfect apyrexia as after the 
paroxysm of an intermittent. 

5. The causes, both predisposing and exciting, are usually dif- 
ferent. The intermittents most usually are the effect of external 
causes, particularly marsh miasma, of cold, and intemperance, or 
they are renewed as already observed, by debilitating causes. 
Whereas, remittents ordinarily occur in a vitiated habit of body, 
so deranged by neglect of the intestinal canal—perhaps proceed- 
ing from bad food, or occasioned by the debilitating operation of 
summer and autumn, by intemperance, exposure to excessive heat, 
&c. And as they arise frequently from internal causes, from the 
state of the system, they also occasionally appear in the winter 
season as well as at other times of the year. And hence those 



328 LECTURE XXVI. 

who do not discriminate between a bilious remittent and a yel- 
low fever, will tell you, forsooth, and very gravely, that they 
have seen the yellow fever in mid-winter! It may be added, 
that it is very prevalent both in town and country — in the latter 
most frequently, occurring in the lowest situations. In a remit- 
ting fever when forming, the patient is oftentimes affected with- 
out the slightest chill ; and the disease is slowly and gradually 
formed. So say Lempriere, Sir Gilbert Blane, Lind, Pringle, 
Niell, and Pym — who have all contended for the peculiarities of 
this form of fever. One day the patient is slightly indisposed, 
another day he is better, on the third day he is worse again. 
Whereas, in the yellow fever you see none of these alternations — 
in that, the disease is uninterrupted from the moment of the at- 
tack until recovery or dissolution takes place. The bilious re- 
mittent is also distinguished by various symptoms, viz : a loaded 
and yellow tongue, a foul offensive breath — the patient complains 
of a disagreeable and bitter taste in his mouth, headache, hot burn- 
ing hands and feet, especially as night approaches. At this time, too, 
a degree of horripilatio takes place, giving a sense of crawling, like 
the impressions created by hairs on the body. In some it creates 
the sensation of cold water running down the back — pains in dif- 
ferent parts of the body are complained of — the appetite is im- 
paired — the biliary secretion is sometimes slow, diminished, or 
altogether obstructed — costiveness follows — his discharges be- 
come more offensive than usual, and of darker colour — his urine 
becomes yellowish and muddy, at least somewhat turbid. In a 
few days after struggling against these symptoms and feelings, he 
is confined to his bed — his fever is increased, and the physician 
is called. Twice a day sensible exacerbations now show them- 
selves — but no perfect apyrexia or intermission follows — each ex- 
acerbation, however, is preceded by a sense of coldness, but not 
the honest, undisguised shaking that ushers in the intermittent. 
Such is the condition of your patient — what is to be done ? His 
whole system is now diseased, not only proceeding from external 
causes, such as marsh miasmata and moisture, and these perhaps, 
combined, but from a vitiated state of his bowels, a torpid state 
of the liver, the season of the year, his diet, and other causes. 
His whole system now exhibits the evidences of more or less in- 
ternal derangement pervading the whole body, showing itself in 
the secretions and excretions as well as the solids of the system. 



REMITTENT FEVERS. 32 f) 

Our object then, must be, if possible, to simplify the disease by 
removing from the system every source of that complicated form 
of the disease which it now exhibits. In other words, to reduce 
it, if practicable, to the intermittent character, that is, to take 
away those internal causes, which give a peculiar malignancy to 
the disease. The means of effecting this are various. 

1st. If the habit be full and the excitement considerable, the 
patient, perhaps, under the influence of the effects of habitual and 
previous intemperance, that is, when an imflammatory diathesis 
prevails, in that case venesection may be advantageously directed 5 
but it is to be done with great caution, keeping constantly in view 
the tendency of this form of disease to the more continued form of 
fever, and especially to the typhus type. But when it may have 
assumed that character and the contagion of typhus superadded, 
constituting it the malignant bilious fever of authors, and in this 
complicated form is communicated from man to man, blood- 
letting is rarely admissible. Such was the case in the late 
typhoid form of bilious fever of Bancker street — vensection was 
altogether inadmissible in the cases that fell under my view. 

2d. Emetics are especially important, not only from their 
effects upon the stomach and biliary organs, but upon the whole 
system. Emetics in the Bancker street fever were generally 
beneficial when early applied — with the exception of those cases 
where the stomach was previously impaired by intemperance or 
active inflammatory symptoms of the stomach, liver, or intes- 
tines, had supervened. Some few instances of this nature occur- 
red, attended with black discharges as in typhus. But from a 
report, published by the Medical Society, it would be inferred 
that many such cases occurred. Not so. A more gross 
imposition on the public mind, I do not recollect to have 
witnessed. They would also lead to the inference that it is yel- 
low fever they describe ; but this is at once contradicted by 
the fact that it continued throughout the winter ; and I also know 
that some of the same committee who have lent their names to 
this fraud, this imposition, did not believe it to be yellow fever. 
They declared this to me themselves — you then will judge. The 
same disease among the blacks occurred at Philadelphia. See 
Dr. Chapman's observations on this subject, who also considered 
it totally distinct from yellow fever. An emetic, says Stoll, fre- 
quently strangles it at a blow, 
29 



330 LECTURE XXVI. 

3d. In like manner, active cathartics, to cleanse the intestines 
of their offensive and putrid contents, should immediately be 
prescribed. 

4th. Relax the surface by sp. mind, and laud, or by antim. 
and calomel combined. "Of all things," says Lind, "it is im- 
portant to relax the body into an intermission." 

5th. Apply blisters early in the disease, and thereby concen- 
trate as far as may be practicable, the irritations of the system to 
a particular part — as far as practicable, convert the general into a 
local irritation. 

6th. If the habit of body be plethoric, and the system is much 
excited, the skin obstinately dry and hot, make use of cold wash- 
ing and cold drinks. But if the system be greatly debilitated, 
use tepid applications, in the form of fomentations to the limbs, 
and cataplasms to the feet; not stimulant, composed of mustard, 
nor applied hot, but emollient ones, consisting of vinegar and 
water, and applied moderately warm. In this case, too, the tem- 
perature of the patient's drinks should correspond with that of 
the external applications. Continue, also, mild aperient medi- 
cines, viz., magnesia, small doses of salts, an occasional dose of 
calomel and James' powders, or an enema daily ; also attend to 
the skin, directing sp. mind., or the saline mixture, as the con- 
dition of the stomach may admit ; also repeat the blisters either 
for the relief of particular symptoms, or as a general means of re- 
moving fever. 

7th. In hot climates the bark is resorted to during the remis- 
sions. There the septic tendency is so great and the powers of 
life are so rapidly prostrated, that this practice may be justifiable, 
and doubtless is proper ; but in temperate climates the early use 
of bark is less necessary, and indeed is generally injurious before 
an apyrexia is obtained. If, however, the system be greatly de- 
bilitated, the milder tonics, as bitters, snake root, chamomile, 
may be safely employed. 

8th. Attend to the air of the apartment and the temperature of 
your patient We have remarked that even intermittents, by 
multiplying their paroxyisms, have a tendency to become remit- 
tents, and ultimately to end in typhus. So remittents are much 
more prone to assume the typhoid character, if attention be not 
paid to personal cleanliness and ventilation ; this is not all, they 
become contagious, especially in apartments where many persons 



REMITTENT FEVERS. 331 

are crowded together. And in RussePs Aleppo, it is observed, 
" that intermittent or remittent fevers of the more malignant 
kind, are seldom seen at Aleppo, unless when imported by persons 
who have contracted them in other places ;" the author thereby 
clearly denoting their tendency to the continued form and their 
contagious character. See Russel's Aleppo, Vol. II., page 302, 
London, 4th edition. 

9th. When remittents are unusually obstinate, if possible, re- 
move your patient to the sea shore, i. e. in the hot season of the 
year ; for this change, from a higher to a lower temperature, this 
new impression upon the sj'stem, frequently carries off both heat 
and fever, as in the remittents of children or diarrhoea infantum. 
When a crisis is obtained or an intermission only, then administer 
tonics, especially the bitters and stimulant nourishments ; but 
during the continuance of fever, the diet of the patient should be 
simple, and then chiefly consisting of vegetable nourishment and 
dilution, with the least stimulant drinks. The admission of fresh 
air into the chamber of the sick, and moderate exercise in the 
open air, then, also will be useful ; but if ending in the typhoid 
form of fever, then the treatment is to be pursued which has 
already been detailed when speakiug on that subject. Allow me 
here to repeat the observation already expressed in favour of the 
effects of opiates given to prevent the return of the exacerbations. 
As in preventing the return of the paroxysms of an intermittent, 
they in like manner prevent the chill and coldness that an- 
nounces the returning exacerbations of the remittent. This may 
be administered in the form of the Dover's powder, or in the fol- 
lowing combination, which is in some instances preferable — R 
tinct. opii, sp. ammon. aa zi., aq. menth. ^ij. M.; a table-spoonful 
every two hours, especially before the exacerbation is expected. 

INFANTILE REMITTENT FEVER. 

To this disease the attention of practitioners was long since 
directed by the valuable publication of Dr. Butler ; and recently 
by the excellent practical observations on the same subject, by 
Dr. Colly. The profession has again been called upon to notice 
this form of fever, which, although of daily occurrence at the 
bed-side, has not been sufficiently regarded by physicians. In 
this country, as I was early taught by my preceptors, Drs. Rush 



332 LECTURE XXVI. 

and Kuhn, and as I have witnessed in my own practice since the 
year 1794, the remittent fever of children is more frequently met 
with than perhaps any other disease of infancy or childhood, if 
we except croup, pneumonia, and the diarrhoea, attendant upon 
teething. Nor is the infantile remittent confined, as observed by 
Dr. Thomas, to children under six years of age ; it is frequently 
met with between that period and the twelfth year. As in the 
bilious remittents of adults, it may be remarked of this fever, that 
it is very generally traceable to derangement of the digestive or- 
gans as its primary seat and source. This is evinced by the loss 
of appetite, the foul tongue, the offensive breath, and the confined 
state of the belly, in the forming stage of this disease. These 
symptoms in a few days are succeeded by those of fever, which 
is of very uncertain duration and violence, and not unfrequently 
vents itself either upon the chest, producing oppressed respiration 
and cough resembling pneumonia, or upon the brain, followed by 
the evidences of phrenitic inflammation, and ultimately termi- 
nating in hydrocephalus internus. This last termination, such is 
the natural tendency and force of the circulation upon the brain 
at that early period of life, may very generally be anticipated, if 
active means be not early employed to empty the stomach and 
intestines, and to unlock the surface of the body by the free use 
of antimony and other diaphoretics, warm bathing, or by blisters, 
to create a new and relatively safe seat of irritation upon which 
the febrile symptoms may vent themselves. Indeed, so con- 
stantly is hydrocephalus the sequela of other diseases, that it may, 
with very few exceptions, be considered as exclusively sympto- 
matic. I have even known pneumonia to be its forerunner. 

Teething is frequently productive of fever, ending in phrenitis 
and hydrocephalus; and I believe, as I have already intimated, 
the arterial excitement occasioned by the use of mercury, so gene- 
rally and so indiscriminately given in the diseases of children, 
has been a prolific parent of this fatal malady, and which has 
oftentimes been remarked to have greatly increased in frequency 
and mortality since the very general prescription of that metal. 
Blackall, Pemberton, and Willan, have all noticed the increase of 
hydrocephalus since the more general use of mercury. 

In as far, therefore, as increased arterial excitement of long 
continuance, whatever may be its type or its source, has a pecu- 
liar tendency to oppress the brain at this period of life, the same 



REMITTENT FEVERS. 333 

consequence is to be apprehended from the remittent form of 
fever now under consideration ; and on this account not only 
calls for the most active means of obtaining a solution of such 
fever, but in an especial manner suggests the employment of such 
remedies as are calculated to divert the current from the brain to 
the other parts of the system. When, therefore, in the progress 
of fever, the brain begins to manifest irritation by pain or by stu- 
por, blisters to the extremeties, and active cathartics, such as an 
infusion of senna manna, and cream of tartar frequently adminis- 
tered until plentiful evacuations are obtained, are among the most 
effectual means of arresting the progress of the fatal train of 
symptoms now to be apprehended. I notice in a particular man- 
ner, the infusion of senna, having administered it in many cases 
of approaching hydrocephalus, and one in which the disease was 
confirmed, with the most decided advantage. The formula I 
recommend to your notice, and which I am in the habit of direct- 
ing, consists of the leaves of senna, cream of tartar, and manna, of 
each 5ss. infused in half a pint of boiling water — a wine-glassful 
every two hours, varying the dose with the age of the child, 



29^ 



334 



LECTURE XXVII. 



CONTINUED FEVERS.— SYNOCHA.— CHARACTERISTIC SYMPTOMS. 
—TREATMENT.— SYNOCHUS VEL TYPHUS. 



The order of fevers which is next to be considered, is distin- 
guished by having no intermission, nor even a regular remis- 
sion, or sensible abatement. That is, whatever remission may 
take place, it wants that regularity of return that we have ob- 
served to belong to those fevers which are denominated remit- 
tents. Synocha, or inflammatory fever, is of this description. It 
is so called from the Greek word cwsxu>, to continue. Synocha, 
or inflammatory fever, may be said to be a state of pure, general 
excitement of the system, without local inflammation, and with- 
out vitiation of the fluids. When a particular part becomes the 
principal seat of disease, synochal fever loses itself in one of the 
phlegmasia, according to the part affected ; and when the fluids 
assume the typhoid type, it also ceases to be the pure, unmixed 
inflammatory fever which we have now in view. Inflammatory 
fever commences with a very slight degree of chilliness — some- 
times none. We have already observed, with regard to the chill 
which ushers in fever, that there is a regular grade of chill, from 
the quartan form of fever, through all the variety of remittent 
forms, to that of the continued type. That is, the greatest in the 
quartan, less in the tertian; still less in the quotidian. And again, 
that it is still diminished in the remittent and continued fevers. 
Accordingly it happens, that in the plague, in yellow fever, and 
the various forms of typhus, as in jail, hospital, and ship fever, 
there is frequently no chill to be perceived whatever. It was also 
observed, that as the chill and shaking are less, heat and excite- 
ment are greater. 

2. In inflammatory fever the pulse is quick, strong, and hard. 
When the fever affects particular parts, as in the local phlegmasia. 



CONTINUED FEVERS. 335 

especially if seated in the more sensible organs of the body, the 
pulse is not only frequent and hard, but peculiarly contracted and 
corded. In typhus fever, again, except in the forming stage, the 
pulse is small, and oftentimes feeble, and attended with cold- 
ness of the extremities, owing to the depressing and deleterious 
effects of contagion ; 'but in synocha, it is full and hard from the 
commencement, even though a sense of chilliness be present. 

3. Inflammatory fever is attended with hurried, and oftentimes 
laborious respiration; but not that anxiety that characterises fever 
from contagion, which primarily affects the nervous system by its 
deleterious operation. The face is flushed, and the whole surface 
hot and dry; but in local inflammation, as in enteritis, the face is 
frequently pale, and the extremities cool. The heat of the sys- 
tem, too, differs from the pungent and peculiar heat of typhus. 
The eyes also manifest this high excitement. They become load- 
ed with blood, and impatient of light. The impulse of the cir- 
culation created upon the head, produces violent headache, and 
a manifest throbbing of the temporal arteries. And with these 
symptoms there is also a sense of burning on the brain, which 
some compare to coals of fire on the head. In some instances, 
coma, or delirium is the consequence of the force given to the 
circulation. The urine is high coloured, and diminished in quan- 
tity. The bowels are costive ; the secretions more or less impair- 
ed. The tongue dry and covered with white fur; and upon 
thrusting it out, the great heat of the body is manifest, even in 
that organ, by the rapid production of vapour from its surface. 
This form of fever is but imperfectly described by Dr. Cullen. 
" Calor plurimum auctus; pulsus frequens validus et durus; urine 
rubra; sensorii functiones parum turbetae." And in the last part 
of it, we (at least in this country) know it to be frequently incor- 
rect, inasmuch as it is oftentimes immediately destructive of the 
sensorial functions, and thereby proves fatal even in three, four, 
or five days. Sometimes inflammatory fever appears as a mere 
ephemera from indigestion. But intemperance in the use of spi- 
rituous liquors, exposure to great heat, violent exercise, fatigue, 
sudden suspension of perspiration, and the other excretions, by 
exposure to cold; as plunging in the river when heated, or expo- 
sure to a shower of rain after labour, upon a warm day, are among 
the most usual exciting causes of synocha. This form of fever 
occurs sometimes in cold climates, and in cold seasons of the 



336 LECTURE XXVII. 

year, but then it frequently runs into the local phlegmasia, there- 
by losing its general character. We see synocha most usually in 
hot climates, or in hot seasons of temperate climates, and then 
it most generally attacks such as are of full, sanguineous ha- 
bits, especially those persons who may have recently changed 
their climate, by coming from a northern to a southern lati- 
tude. The impulse given to such habits of body by the causes 
which have been enumerated, is not only violent, but soon 
produces an engorged state of the brain, of the liver, the 
stomach, the uterus, &c, and if not immediately relieved, the 
system is broken down by hemorrhages, either from the vessels 
of the brain, or from the liver, or the intestines. In the torrid 
zone it assumes a greater malignancy of character, constituting a 
peculiar form of fever, from the typhoid state of body which it 
there assumes. This is not all. Under peculiar circumstances it 
is constituted a contagious disease, and propagates itself by con- 
tagion, in this new character, which it puts on in the tropics. 
Under these circumstances of climate, it is known by the appel- 
lation of yellow fever; and as I think has been already shown, it is 
or is not contagious, depending upon the condition of atmosphere 
in which it originates, or into which it may be introduced. In 
our own climate, in the hot seasons of the year, we have also an 
ardent fever, or causos, but which exhibits the symptoms of a 
pure, unmixed synocha. In the southern states, this indigenous 
fever is known by the name of the stranger's fever, because stran- 
gers to the climate, especially from the north, are most usually 
the subjects of it ; and to them, too, it' is frequently fatal in a few 
days. In the torrid zone, when the heat is above 85°, for a long con- 
tinuance, the same synocha in the stranger becomes a yellow fe- 
ver, and ultimately a contagious disease; i. e. in a foul state of the 
atmosphere, so rendered particularly by concentrated human ef- 
fluvia. The first is the effect of climate ; but its contagiousness 
depends not merely upon the condition of the patient, but the 
state of the air surrounding him — if pure, the disease is extin- 
guished in the individual — but if foul, as from confined human 
effluvia, as on ship-board, in hospitals, in garrisons, in camps, or 
in confined dwellings of any sort, the disease is communicated to 
other persons, who may be thus exposed, particularly the full 
habited stranger from the north. Every summer we have the 
causus or ardent fever in the form of synocha, and if it proves 



CONTINUED FEVERS. 337 

fatal, ends in local congestions of the brain, the lungs, liver, &c, 
and in hemorrhages from the stomach, bowels, nose, or some of 
the organs mentioned. A sort of general sphacelus of the system 
is the result of this general inflammatory action, which in our 
climate, may with great propriety, be called pure or simple in- 
flammatory action, compared with the compound character it 
assumes in the tropics, and which is rendered thus compound by 
the septic condition of body, the effects of heat, and other causes. 
Accordingly, we find in our synocha, where it proves fatal, pete- 
chae and the yellow skin are rarely produced; but in the tropics, 
a peculiar state of the fluids is induced, exhibiting great malig- 
nancy in their quality, besides the waste of energy, the effects of 
simple excessive action. Then the humours secreted are peculi- 
arly modified, and by this specific quality become capable of re- 
producing precisely the same disease in those who may be pre- 
disposed to fever — especially the northern man — and indeed, 
sometimes it is communicated to the native of the tropics; but 
this is comparatively of rare occurrence. In the northern lati- 
tudes, synocha is not usually communicable. I mean that form 
of it which is engendered here. It is not communicable because 
that peculiar condition of the fluids, and those peculiar secretions, 
the effect of it, are not produced. Synocha, with us, breaks 
down the whole system by simple excessive action, like phleg- 
mon, which ends in the destruction of the part, and simple ulcer 
is the consequence. But in a hot climate, the phlegmon fre- 
quently ends in vitiated and malignant ulcer, spreading fresh in- 
flammation wherever its matter extends. The fever of the tro- 
pics, in like manner, terminates in a malignancy of the whole 
system, which, under the circumstances before mentioned, engen- 
ders the pestilence . Even in temperate climates, sometimes, syno- 
cha is protracted (but rarely) into typhus or synochus. But this is 
the effect of other causes, to be hereafter noticed. When the tem- 
perature of the atmosphere is as high as 80°, and for a long con- 
tinuance, the foreigner becomes the subject of ardent fever ; and 
which, too, perhaps proves fatal in a few days, exhibiting many 
of the characters of yellow fever of the tropics; and, indeed, if 
his system was in the septic state, as on ship-board is the case 
with seamen and soldiers, yellow fever would doubtless be the 
product ; i. e. ardent fever with the typhus malignancy of the 
system superinduced, would constitute the yellow fever, as it 



338 LECTURE XXVII. 

appears in the tropics. But typhus alone is of a different charac- 
ter, and synocha alone is different; but the two being compounded 
in an athletic habit of body, in a climate where the heat is gene- 
rally at or above 80°, and in a septic state of the air, yellow fever 
is not only generated, but is communicated to others, especially 
to the men of the north, and even sometimes to the native. For 
these requisites, then, we need not go to Siam, but to any part 
of the tropics — to the coast of Africa, to the West Indies, or to 
South America. In this climate, synocha is more simple and 
pure in its character, except when introduced by contagion. The 
treatment of it is also simple, for we have but one general indi- 
cation, which is to reduce the excessive action of the system, 
duly regarding, however, the habit of body, the season of the 
year, climate and tendency of the disease. 

The means of fulfilling this indication are, 

1st. Venesection, general and local, directed by the tone of 
circulation and strength of the patient's constitution, the dark 
colour and viscid consistency of the blood, but not the buffy coat. 

2d. Open the bowels, especially by the use of saline purga- 
tives, Glauber, Rochelle, sulphate of magnesia, &c. 

3. Sudorifics — sp. mind., and antimonials. 

4. Cold washing — if no local inflammation exists, and the skin 
be hot and dry. I have objections to the clay-cap, prescribed for the 
relief of the pain of the head, and other affections of the brain. 
The advocates for the constant application of cold washing and 
the clay-cap forget the function of perspiration, and its office of 
carrying off the heat of the body, when by their applications 
they suppress this important discharge from the surface of the 
body. Instead of constantly covering the head with clay, as is 
done by some physicians, they may as well extend their prescrip- 
tion by covering the whole body at once with clay, for this will 
be the consequence of their practice, sooner or later. I have 
never known it otherwise than a fatal practice. 

.5th. Warm, or rather tepid bathing, as a means of relaxing the 
surface by its emollient effects, and for the purpose of conveying 
off the excessive heat of the body. 

6th. Blisters, to convert it into a local inflammation, and for 
the relief of particular symptoms, as violent headache, delirium. 

Diet of the patient. — Bread and water; acid fruits; fresh, do. 
as oranges, &c. ; lemonade; toast- water; cream of tartar; cream 



i 



CONTINUED FEVERS. 339 

of tartar, with tamarinds; cream of tartar whey; buttermilk whey. 
Regimen. — Clothing light, but sufficient to keep the skin re- 
laxed; covered from the air. 

SYNOCHUS OR TYPHUS. 

The next subject, agreeably to our arrangement, is synochus or 
typhus, which we consider as one and the same disease, though 
they are made different genera by Dr. Cullen. 

The word typhus, is a term of Greek derivation ; it comes from 
the verb tv^, to inflame. 

Dr. Cullen thus defines typhus fever : Nosology, p. 71. " Mor- 
bus contagiones; calor parvum auctus; pulsus parvus, debilis, 
plerumque frequens ; urina parvum mutata ; sensorii functiones 
plurimum turbetse; vires multum imminutae." How far does 
this correspond with the disease at the bed-side ? It differs from 
it in several particulars. Dr. C. states, that the heat is but little 
increased in typhus ; on the contrary, for the most part, in a cer- 
tain stage of the disease, the heat is very much increased and 
much more intense, and a very peculiar biting heat too. It is 
acer digitori que urens : so say the best practical writers, 
and such is the fact, as you may all daily witness in our hospital 
and our alms-house. Dr. C. also observes, that the urine is but 
little changed; on the contrary, it is frequently very turbid, like 
small beer, especially as the disease advances. With these excep- 
tions, his definition expresses the most prominent features of 
typhus. 

Dr. C. next proceeds to divide the genus typhus into two spe- 
cies, which he denominates typhus mitior, or mild typhus and 
typhus gravior, that which is more severe and violent. This, 
in my opinion, is an useless, and indeed an incorrect divi- 
sion. It is making a distinction where there is no difference. 
He himself admits in a note,* (which frequently, as I have 
said before, is at variance with his text,) that it is wrong 
to distinguish diseases by different names, that differ only in 
degree. His expression is "morbos gradu solum differentes, 
nominibus diversis insignire, nequequam convenit ;"' and he fur- 
ther subjoins, that he has not perhaps arranged them accurately, 
as the limits are by no means settled. " In hac re autem, cum 

* See Nosologia Method, p. 71. 



340 LECTURE XXVII. 

limites neutiquam accurate ponere disunt me accuratum fuisse non 
dixerim." Under the one species, viz. the mitior, he professes 
to place the milder form, called nervous fever ! and under the 
latter species, the gravior he wishes to be considered as placing 
putrid fever, that is, where the humours more particularly show 
a diseased or putrid state. 

Still again in his notes, he unfortunately adds, that in every 
species of typhus, he thinks there is a tendency in the humours to 
putrefaction. " In omni typho humorum in putredinem proclivi- 
tatem adesse puto." A very strong expression certainly, of his 
opinion on the state of the fluids, in fevers; and it is to be regret- 
ted that in his first lines he had not given less attention to the 
nerves and more to the fluids. 

There is certainly, as you must perceive, and as Dr. C. himself 
in so many words admits, no foundation for these distinctions of 
typhus : they only serve to embarrass without leading to any 
possible good, either as it regards the nature of the disease or its 
treatment; for every nervous fever is attended with a putrescent 
state of the fluids; and every putrid fever is attended with a de- 
ranged state of the nervous system ; and this too is the case, 
whether this typhus state be the effect of long continued action 
producing the morbid state of the fluids, or it be produced by a 
taint introduced into the system, the produce of other diseased 
bodies. 

But strange to tell, Dr. Cullen with all his scruples of con- 
science, relative to the distinctions we have noticed, is not even 
contented with those two forms of typhus, and has accordingly 
constituted another genus ; another twin brother of typhus, which 
he calls synochus ! ! This he defines to be, " morbus contagio- 
sa, febris ex synocha et typo composita, initio synocha pro- 
gressu et versus finem typhus!!" A contagious disease, com- 
pounded of synocha and typhus, first synocha, afterwards as it 
proceeds,, and towards its termination, a typhus. But, let us ask, 
is he himself satisfied with this new genus, as distinct from ty- 
phus ? 

Let us again look, for I have already said that Dr. Cullen, in 
his notes, deposites all his doubts of the correctness of his text, 
and indeed he frequently here gives us more truth than he does in 
his text. Here again, in a note, he candidly observes, that be- 
tween typhus and synochus, he is unable to ascertain the exact 



CONTINUED FEVERS. 341 

limits, and is in doubt whether they are really different genera. 
or if different, to which of them the synonyms of authors apply. 
The following is his own language : 

"Inter typhum tamen et synochum limites accuratos ponere non 
possum : et an revera pro diversis generibus habenda, vel positi^ 
diversis, utrieorum synonyma auctorum referenda sunt dubito. ,? 
A very honest doubt ; and if he doubts, we surely may be per- 
mitted to doubt the correctness of his distinction, as he admits 
himself, that it is a distinction in which he cannot find the differ- 
ence. You will therefore, gentlemen, not be surprised that I 
have made these* two genera of Dr. Cullen, one and the same, 
calling them typhus or synochus, for neither we nor Dr. Cullen 
himself, can distinguish between them. On this subject we have 
already been so free, that I have few observations to make at thi? 
time, and these will be very short. 

Typhus or synochus we remark, is very generally more or 
less inflammatory in its first stage : i. e. when the poison creating 
the disease, first acts on the system ; whether gendered within it 
or introduced from without, it excites irritation, manifesting that 
stage of the disease which may properly be denominated the in- 
flammatory stage, or the stage of remittent ; that is, it is synocha 
in its commencement, though it is typhus in its progress and its 
termination. Armstrong too, takes this view of this subject. 
The symptoms, as it affects the brain, nerves, heart, arteries, 
exhalents and the excretions, the absorbents and the fluids of the 
system, have all been very fully detailed. 

The causes also of this form of fever have been particularlv 



* Dr. Dumar, I observe too, in a late publication, refuses to admit Dr. Cullen's 
distinction between typhus and synochus. The following is Dr. Dumar's obser- 
vations : 

" I have not used Dr. Cullen's distinction of synochus and typhus ; because I 
do not believe that the distinction exists in nature. I have never seen an in- 
stance of typhus fever according to his definition. "All our severe fevers begin 
with excitement and terminate in debility, or are instances of synochus : 
although in truth, they are the identical diseases from which Dr. Cullen drew his 
description of typhus, and are genuine examples of the only typhus fever which 
exists." 

Dr. Cullen's system, says Dr. Good, like himself, is a work of no ordinary 
stamp ; it is full of immortality, but mixed up with weak and perishable materials. 
— Good, vol. ii. p. 119. 
30 



342 LECTURE XXVII. 

enumerated, viz. marsh effluvia, under peculiar circumstances ; 
confined human effluvia, decomposed animal matter, salt provi- 
sions, want of fresh vegetables, &c. and contagion. 

Of the first, we have seen examples at the Walkiil, in the 
newly cleared grounds of our southern states, and in the wet 
marsy grounds of Walcheren, in the island of New Zealand. 

The typhus of Great Britain, which occurs in their large cities, 
and in their manufacturing towns, are the products of confined 
human effluvia, the results of the filthy mode of living, unavoida- 
ble among the poor, where the resources of life are so scanty, 
compared with their population. Ship and jail fever are of the 
same description, only assuming if possible, a still greater degree 
of malignancy, as we have seen exemplified on board of the Irish 
ships which have been employed in bringing the sons of St. 
Patrick to this country. And that typhus or synochus is also 
produced by contagion, as well as gendered by the causes we 
have enumerated, I trust is admitted by all who are practically 
acquainted with disease. Closet physicians may speculate about 
it, and because they cannot comprehend the why and where- 
fore, cut the knot by denying the existence of contagion in toto. 
But, while the works of Huxham, Lind, Blane, Pringle, Rush, 
Saunders, McGregor, Gregory, Home, Cullen, Lempriere, For- 
dyce, Cleghorn, Chisholm, Heygarth, and Armstrong remain, 
the positive testimony which they give you on this subject, is 
not to be affected or overturned by the breath of speculation, or 
the airy nothings of imagination. 

I may indeed refer you, passim, to every practical writer, 
whether at home or abroad, for the evidence of the contagious 
character of continued fever under the peculiar circumstances 
which have been enumerated ; the hospitals of London, of Edin- 
burgh, of Aberdeen, furnish to their pupils continued examples on 
this subject ; and it is to be regretted, that some of their American 
pupils had not spent their time more profitably, and brought with 
them to this country, more correct knowledge of this subject, 
more facts and fewer speculative opinions. 

We see it, according to Drs. Young and Gordon, even com- 
municated to the lying-in women, giving even to puerperal fever 
this contagious character, not ordinarily attached to that disease. 
Nor is it confined merely to fevers and other diseases of the whole 
system ; but this state of the air influences the character of many 



CONTINUED FEVERS. 343 

local diseases — hence indeed has arisen the peculiar form of ul- 
cer, called hospital ulcer, noticed by practical writers. " Every 
ulcer," says that accurate observer, Dr. Blane, "acquires pecu- 
liar malignancy when such a state of the air taints the bodies of 
those who labour under them." 

But we need not go from home for illustration, we see it in our 
public institutions, and occasionally in our private families. In 
my own family, in the present winter, I have witnessed the intro- 
duction of this disease by contagion ; this fact alone, must con- 
found all who could have before entertained a doubt on this subject. 
The most malignant form of typhus fever, as it prevailed among 
the soldiers stationed in the neighbourhood of this city, was intro- 
duced into my family by a son of one of my servant women. I 
could not send him from my house to deprive him of his mother's 
services during his sickness : the consequence was, that my chil- 
dren, who frequently went to- his room, took the disease from 
him, and they had nearly perished with it. And in all, it put on 
the same character, the same malignant form of typhus, attended 
with all those effects of the nervous system, and the vitiation of the 
fluids and broken texture of the solids that have been noticed, 
bleeding gums, bleeding blisters, blood boils, and unceasing de- 
lirium. I still look back with horror at the destruction 1 had 
nearly witnessed, by the visitation of that disease, and cannot but 
cherish the strongest feelings of gratitude for the preservation of 
my children on that distressing occasion. 

The indications of cure in this form of disease, and the means 
of fulfilling them, have been also minutely pointed out, as consist- 
ing, in the first stage, of the means of reducing the excitement 
produced, at the same time keeping in view the termination of 
the disease, and the debility which ensues. We have especially 
pointed out the use of venesection, emetics, cathartics, sudorifics, 
and the alterative treatment, to prevent the poison from wasting 
the system by its action, i. e. by counteracting, by means of evacu- 
ations, the irritation it occasions, until the poison creating the dis- 
ease, shall itself be worn out, and the putrescent state of the sys- 
tem be removed. This is an important idea to be kept in view, 
and that our remedies be so directed, that thereby the poison of 
the disease should do the system as little harm as possible. 

In the treatment of the second stage, our attention has been 



344 LECTURE XXVII. 

directed to the means of counteracting the debility induced in the 
solids, and the diseased condition of the fluids. 

Stimulants and tonics, both in the form of medicine and diet, 
have been particularly directed for the first of these objects ; 
while the most powerful antiseptics which the materia medica or 
our food can furnish, and other means of counteracting the putres- 
cent state of body, including the use of external applications, ven- 
tilation, aand other means of purifying the air, &c, have all been 
so minutely detailed, as, I trust, to make any further observations 
at this time wholly superfluous. 



345 



LECTURE XXVIII. 



DYSENTERY. 



Dysentery being a disease of frequent occurrence, and being 
always attended with danger, is highly important. It is especially 
important during war, when the disease usually assumes a con- 
tagious character, and, superadded to the danger to the individu- 
al, is that of communicating it to others. The term is derived 
from 8d$, difficult, and svtspov, intestine; thereby denoting a de- 
ranged state, more immediately, of the intestines. 

Dr. Cullen has very properly denned dysentery to be " Py- 
rexia contagiosa; dejectiones frequentes, mucosae, vel sanguino- 
lentae, retentis plerumque foecibus alvinis; tormina; tenesmus:" 
a contagious fever, attended with frequent mucous or bloody 
stools, (or rather, he should have said, with frequent efforts to go 
to stool, and then very inconsiderable discharges.) " The foeces," 
he adds, " are for the most part retained, attended with gripes 
and tenesmus." By tenesmus is meant a straining and frequent 
inclinations, but unsuccessful efforts to discharge the contents of 
the bowels. 

From the bloody discharges attendant upon dysentery, it is 
commonly known by the vulgar name of the bloody-flux. As I 
formerly observed, Dr. Cullen has strangely placed it among his 
profluvia; whereas it is most frequently the very reverse of pro- 
fluvia, being most usually attended with diminished instead of 
increased discharges. Remember, I refer more particualrly to 
epidemic dysentery, not only because it is a highly contagious 
disease, but also to distinguish it from that local affection of the 
bowels, consequent upon diarrhoea, or the effect of mere local 
irritation in the intestines, such as is occasioned by aloes, or mer- 
30* 



346 LECTURE XXVIII. 

cury, or teething, and which is unaccompanied by the typhoid 
form of fever, that characterises this disease. In the disease re- 
ferred to, under the appellation of dysentery, I mean the dysen- 
tery of camps, as described by authors — the " febris intro versa" 
of Sydenham, and which is not merely a disease of the intestines, 
but a disease of the whole system. The circumstances under 
which it occurs, the causes which give rise to it, the character of 
the fever attendant upon it, the season of the year at which it 
most generally appears, have all induced me to place it among the 
continued fevers. In other words, to consider it as a disease of 
the whole system, and not as a mere local affection of the bowels. 
The treatment, too, which is founded upon this view of the 
disease, is more likely to be successful. Otherwise our attention 
may be directed to the bowels alone, while the state of the whole 
system is neglected, and the disease is thereby rendered fatal by 
those circumstances, having overlooked forms which give it ma- 
lignancy, and render it a dangerous disease. 

Dysentery, for the most part, occurs in summer and autumn; 
that is, about the same time with intermittent, remitting, and ty- 
phus fevers; and sometimes proceeds from the same causes. Ac- 
cording to Huxham, it has occurred as an epidemic in the spring, 
and it has also continued through the winter; but winter generally 
checks its progress, as it does the plague and yellow fever. Pure 
dysentery never assumes the intermittent or remittent forms of 
fever, but always the typhoid, except when complicated with 
them. Even in the same ship, in some instances, the two differ- 
ent diseases have been known to exist at the same time, without 
the one yielding to the other. A case is related by Dr. Blane, 
where two ships' crews were mixed — the one was affected with 
dysentery, the other with fever. In another place he observes, 
that even two different persons, owing to constitution, will be at- 
tacked, one with fever, the other with dysentery. Dr. Harty, 
however, is of opinion that dysentery is contagious only when 
combined with typhus fever; and that its contagiousness is only 
derived from the fever accompanying it. It is true that dysen- 
tery is only contagious sub modo, depending on the state of the 
surrounding air. In private families it is not always contagious, 
owing to cleanliness, state of the air, &c. ; but in an impure air, 
both the disease itself is rendered more malignant, the secretions 
acquire additional virulence, while the air itself is peculiarly fit- 



DYSENTERY. 347 

ted as the vehicle of conveying, or rather of multiplying the con- 
tagion effused from the diseased body. 

Zimmerman justly ascribes to this cause alone its contagious- 
ness: " Hence," says he, " it prevails among the lower ranks, 
where their houses and their persons are filthy;" and observes, 
" that it is only infectious as cleanliness is disregarded." But 
although filth may generate it, and give malignancy to the dis- 
ease, a specific contagion will, in some cases, propagate it, even 
where cleanliness is observed, and in the pure air, too, of the 
country. This was remarkably the case in two families, some 
years since, in the country, on Long Island. The same fact has 
been remarked of yellow fever, jail fever, and other contagious 
diseases. That they acquire such malignancy that the disease is 
communicated from individual to individual, independently of 
the state of the air. This, however, is not usually the case; but 
these facts are important as they demonstrate the specific charac- 
ter of those diseases, and the communication of them by a speci- 
fic material. Others consider the peculiar mucous discharge, 
which takes place from the bowels, as the only contagious matter 
or vehicle of the disease! This is but one of the media of com- 
munication. In other contagious fevers, the various excretions 
of the bowels, the skin, and the lungs, all communicate the speci- 
fic poison of disease. Dysentery also appears more frequently in 
warm than in cold climates, especially in persons going from a 
northern to a southern latitude; and more particularly those who 
add to their septic habit of body by living principally upon ani- 
mal food, as is the case on ship-board, especially transports. The 
same thing is observed of malignant fevers in general. Hence 
dysentery, as well as those fevers, are so prevalent in hot latitudes, 
as in the West Indies, the East Indies, in South America and Africa. 
Dysentery appears also during and after wet seasons, in those cli- 
mates, especially when the rains succeed to great heat, and the 
body is consequently in a septic state — the perspiration being 
then suddenly checked, the bowels are immediately affected. The 
febrile affection, that is produced in this state of the system, and 
in the condition of the intestinal canal that is occasioned by the 
excessive use of animal food, the accumulation of human effluvia, 
and the want of fresh vegetables, is immediately turned in upon 
the intestines, which become the chief seat of its irritation; hence 
very properly called by Sydenham, " febris intro versa," or fever 



348 LECTURE XXVIII. 

turned in upon the intestines. " This disease," says Pringle, " is 
always most numerous and worse after hot and close summers, 
especially in fixed camps, or when the men lay wet after a march 
in warm weather." Bontius, too, remarks that the hottest weather 
produces that disease when the nights begin to be cold. Upon 
the same principle, dj^sentery also frequently occurs in the hot 
seasons of temperate climates, as well as in the hot latitudes which 
have been noticed. An impure atmosphere, rendered so by many 
persons being crowded together in small apartments, as on ship- 
board, both predisposes to, and in some cases, gives rise to dysen- 
tery, especially in conjunction with the use of salted or putrid 
provisions: for, as before remarked, the excessive use of animal 
food, and the want of fresh vegetables, has great agency in indu- 
cing this peculiar condition of the intestinal canal, necessary to 
constitute dysentery. Putrid effluvia, i. e. exhalations from pu- 
trid animal matter, are also among the exciting sources of dysen- 
tery. Dr. Donald Monro says, it is always produced by obstruct- 
ed perspiration, and exposure to putrid effluvia. (See my letters 
to Dr. Currie, stating the cases of dysentery occasioned in 1798, 
by the effluvia of putrid beef.) Thirty-eight of forty persons en- 
gaged in removing and unpacking putrid beef, were attacked with 
dysentery, at the very time, too, that yellow fever prevailed in 
part of the city. Subsequently it was introduced in the neigh- 
bourhood of this putrid atmosphere, and produced the most deadly 
effects, extending itself as far as that foul atmosphere extended. 

Marshy and moist situations are among the causes of dysentery. 
They not only act by the vapours arising from decomposed ani- 
mal and vegetable matters, abounding in such situations, but also 
by the cold which such moisture produces, and the check of per- 
spiration which is thereby occasioned. " Accordingly" says 
Pringle, u armies thus encamped rarely escape." 

Cold is another powerful exciting cause of dysentery; " espe- 
cially," says Lind, " the alternate action of heat and cold." Dr. 
Blane remarks, " that exposure to cold produced dysentery in a 
vessel that had been perfectly healthy, and where the greatest 
cleanliness had been observed. Upon leaving New York," he 
adds, " the first cold weather induced a dysentery, which cut off 
sixteen of the crew." 

When dysentery may have been generated by any of the causes 
which have been enumerated, it is afterwards propagated by a 



DYSENTERY. 349 

specific contagion. I say, a specific contagion, because precisely 
the same disease is reproduced, with all its peculiarities. The 
same peculiar affection of the bowels, and the same character of 
fever are the consequences. Whereas, obstructed perspiration 
alone would produce, under other circumstances, diarrhoea, or 
cholera morbus, or some of the phlegmasia; or, if the contagion 
was in the system, such check of perspiration would be an ex- 
citing cause of dysentery; but contagion alone produces dysen- 
tery, and few other diseases prevail when dysentery appears. 
Like other contagious epidemics, it generally takes the command 
and makes all other diseases obey; and it is reproduced in all 
with precisely the same kind of symptoms ; that is, in all who 
are predisposed to receive it; for in some it is more easily lighted 
up than others, as a man, labouring under dysentery, introduced 
on board ship, will spread the disease through a whole crew, be- 
cause that crew, by their habits of living and vitiated state of body, 
are rendered very susceptible both of the typhoid form of fever, 
and the irritation of the bowels peculiar to dysentery. This was 
the case, according to Dr. Blane, in the Torbay ship-of-war, in 
August, 1780. "The crew," he states, "were predisposed to 
acute distempers, as was to be expected at that season of the 
year; and a great number of them being crowded together, as is 
usual in ships of war. In this state of things a man was brought 
on board, ill of dysentery. Dysentery," says Dr. Blane, " be- 
came the prevailing disease.* But again," says Dr. Blane, u if 
instead of a dysentery any other fever had been introduced, such 
fever would have been the prevailing disorder." Different habits 
of life, and consequently different habits of body, have their 
influence in determining the character of a disease; the conta- 
gion of typhus fever being introduced among puerperal women, 
puerperal fever, with all its characteristic symptoms, is the result. 
In like manner, owing to a peculiar diet, in connexion with bad 
air, a predisposition may exist in the intestines to dysentery; 
while in others, not thus prepared, the same typhus taint will not 
produce dysentery, but typhus fever. This fact is stated to have 
occurred in a ship employed as a transport ship from England to 
New South Wales. The crew of the ship were ill of fevers; 
meaning ordinary typhus, or ship fever. But the convicts whom 

* Dysentery of Seamen, p. 44& 



350 



LECTURE XXVIII. 



they had received from prison, became the subjects of fluxes; i. e. 
dysentery, owing to something peculiar in their habits, predis- 
posing to dysentery. — (See Blane, p. 449.) These two diseases, 
therefore, it appears, are in some cases vicarious, depending on 
particular circumstances or accident, though arising from the 
same causes. Weak and exhausted habits are most susceptible of 
this disease. Fatigue, vexation, and fear, peculiarly prepare the 
body to become affected by dysentery as by other contagions; and 
hence tonics frequently are the means of preventing it in this, as 
in others. (See Sir George Baker's Treatise de Dysenteria.) 
Not only so, but these causes render it more violent in degree. 
The same fact is observed of the contagion of small-pox. The 
debilitating preparation, formerly fashionable, as preparatory to 
inoculation, almost invariably rendered the disease more virulent 
than it would otherwise have proved. (Example of Dr. Coch- 
rane's, the Surgeon General, of want of medicine to prepare the 
American troops for inoculation, during the revolutionary war, 
when stationed near New Brunswick. They all had the disease 
in so mild a form that the fact was notorious. See Thacher's 
Military Journal.) 

Contagion itself, is only in some cases a predisposing cause of 
dysentery, while cold, fatigue, intemperance, or other occasional 
causes, shall excite it into action ; as we have seen to be the case 
with intermitting and remitting fevers. But when dysentery is 
once generated, contagion in that case becomes the chief exciting 
cause. This is communicated, most commonly, though, as said 
before, not exclusively by the excrements, by moving of public 
privies, or by neglect of cleanliness in retaining the excretions in 
the apartments of the sick. Infected clothes are also oftentimes 
the vehicle of the contagion, and from which not only the wearer 
but those who come near, receive the infection. In some instances, 
according to Dagner's history of the disease, it has been as epi- 
demic as the plague ; " but it is generally true/' says Sir John 
Pringle, " that the infection spreads more slowly than most epi- 
demics." 

Dagner again observes that dysentery is not less infectious than 
the plague itself, (this, however, is somewhat questionable,) and 
that, like many other contagious diseases, it is oftentimes com- 
municated to the foetus in utero. Women thus situated, fre- 
quently, however, escape, as in the example of Mrs. Miller, and 



DYSENTERY. 351 

women in the Hospital, mentioned to you some time since, who 
went on to her full time and bore a living and healthy child. 
But the most common of the exciting causes of dysentery, is the 
check of perspiration by cold in those who are prepared for the 
disease. Zimmerman accordingly observes, and which is in cor- 
respondence with this fact, that warm drinks and perspiration, 
with a moderate quantity of food, (which, by the by, he should 
have restricted to vegetable food,) and temperance as to liquors, 
are among the most effectual means of prevention, and, that they 
render the disease mild when its subjects are attacked. Wilson 
enumerates among the causes of dysentery, an unusual quantity of 
bile, and that of a dark colour, implying, says he, a vitiated state 
of that secretion. This, too, he remarks, is confirmed by the dis- 
ease spreading where this is the case. But it is very plain that 
Wilson does not understand the connection that exists between 
dysentery and the state of the biliary secretion. This obstruc- 
tion of the bile is doubtless the consequence of bad diet, that is, 
of an undue proportion of animal and salted provisions, or per- 
haps of the extensive uses of them and the want of fresh vegetables ; 
for as I have observed to you when speaking of the nature of 
diet, it is the effect of fresh ascescent vegetables and acid fruits, 
to promote the secretion of bile (as butchers tell us too, is the 
case with cattle living on grass instead of hay,) and of the want 
of them to diminish the secretion. This obstruction then proves 
an aggravation of the disease by retarding the peristaltic motion 
of the intestines, and thereby promoting the putrefaction of the 
contents of the intestines. It is also ascertained that bile present 
in the intestines has a directly antiseptic operation upon the 
contents. In that case its absence may assist us in accounting 
for the more rapid putrefaction and more virulent condition 
of its contents. — (See Wilson's Treatise.) We now come to the 
symptoms of this disease. The other characteristic symptoms of 
dysentery are well marked in the definition given of it by Dr. Cul- 
len. Notwithstanding his objections to the humoral pathology, 
he admits the putrefaction of the fluids and the contagiousness of 
diseases which derive their character from the circulating fluids 
and the excretions which take place from those fluids. And 
especially making the contagiousness of the disease an essential 
part of it ; for it is of all things an essential character of dysen- 
tary under the circumstances favourable to the propagation of 



3.52 



LECTURE XXVIII. 



contagious fevers in general, and ought always to be kept in view 
by the physician, and that too, whether the disease appears in the 
camp or the private family. Not so, says Wilson, adding that 
this part of Dr. Cullen's definition, calling it a contagious pyrexia, 
might be dispensed with altogether. Let me remark to you, 
gentlemen, that you will find Wilson's chapter on this subject a 
very heterogeneous one, and that the author has no correct view 
either of the nature of the disease or the treatment of it. He has 
merely strung together his remarks from the writings of others, 
and those not the best, without, as I believe, having him- 
self, the least practical knowledge of dysentery. He never had 
that opportunity. I knew him well as my fellow student, and 
know his pursuits to be those of the closet, not the practical phy- 
sician. His indications of cure, to be sure, would lead you at 
first view to suppose he had carefully examined the subject, for 
he very soberly makes two indications — but what are they? viz . 
to procure the evacuation of natural foeces, and as soon as this is 
accomplished, to restore tone to the bowels. A very local view 
indeed, and such, as in my opinion, shows his total want of essen- 
tial acquaintance with this subject. But Dr. Cullen's, you will 
find to be little better, for he makes spasmodic constriction of 
the bowels the proximate cause, and of course antispasmodics the 
chief remedies! Wilson, too, as you will find, evidently com- 
pounds the local irritation consequent on diarrhoea with the 
dysentery of camps. It is important then for us to attend to the 
symptoms of dysentery, that we may arrive at some general de- 
ductions relative to its nature, and that from thence we may ob- 
tain correct principles to guide us in its treatment. It may be 
remarked that dysentery appears in two shapes, that is, as it re- 
gards the part of the body first affected. When it is generated 
in the individual, the first symptoms of the disease manifest 
themselves in the bowels, producing pains, tenesmus, and conse- 
quently a febrile state of the whole system. But when it is the 
effect of contagion the whole system manifests its operation, and 
soon after the bowels, that is, exhibiting at first all the symptoms 
attendant upon the invasion of typhus fever, viz : chill, heat, 
thirst, a dry skin, and, in a short time, these are succeeded by irri- 
tations of the bowels, to which the subject is peculiarly predis- 
posed by the circumstances under which dysentery usually ap- 
pears. Wilson says that the fever of dysentery is sometimes a 



DYSENTERY. 353 

synocha throughout the greater part of its course. Dawson, too, 
in his nosology, expresses the same views. He, however, ad- 
mits that it is more frequently of the typhus form, and that when 
this is the case the danger is very great. This, I would re- 
mark, is very true in every case of real dysentery — not that form 
of it which he states to begin with diarrhoea, which he says is 
often the case. From this assertion alone, I should suppose Wil- 
son had never seen a case of genuine dysentery. On the con- 
trary, so far from diarrhoea, it begins by the want of evacuations 
or rather frequent efforts, but attended with very small and very 
inconsiderable discharges. Another circumstance which would 
lead us to distrust his views on this subject, is his observation, that 
dysentery is sometimes a disease of many months duration. On 
the contrary, being a very severe and an acute disease, it is ne- 
cessarily a disease of but few days continuance. It is evident 
then that Wilson has confounded a mere morbid sensibility 
of the bowels, the consequence of diarrhoea or dysentery, 
with dysentery itself. In the first place then, the symptoms 
of dysentery are the symptoms of general fevers of the typhus 
type, manifesting considerable irritation of the nervous system, 
viz : chill, nausea, vomiting, frequent pulse, which is sometimes 
weak early in the disease, as after other species of contagion. 
This, however, is not oftentimes the case in the commencement, 
for generally the excitement of the arterial system is very mani- 
fest; but dysentery never exhibits the symptoms of typhus fever 
alone, as Wilson asserts, without an affection, or the usual irrita- 
tion of the bowels, for these very soon succeed. Where they 
appear late, Wilson calls it a complication of typhus and dysen- 
tery! I assert that true dysentery is always of the typhoid 
tendency and character ; and that, whether generated within or 
introduced by contagion. Nor do the general or constitutional 
symptoms depend on the local, as Wilson states, (p. 414.) On 
the contrary, both the general and the local irritation are to be 
considered as essential to true dysentery. Blane, however, is of 
opinion that the affection of the bowels is only symptomatic. But 
were this the case, we should see few cases of typhus fever with- 
out the local symptoms attendant upon dysentery. In addition 
then, to the general symptoms of typhus fever, this disease is at- 
tended with pain in the bowels, and which, as in enteritis, is 
increased upon pressure. This pain appears sometimes about the 
31 



354 LECTURE XXVIII. 

navel, affecting chiefly the small intestines which occupy that part 
of the abdomen. Most usually, however, it affects the stomach, 
and the part of the colon passing in its vicinity, attended with 
irritation in the rectum and anus. Not, however, confining itself 
to the anus, but extending to the hips and through the pelvis. In 
some instances, Cleghorn observes, that the pain extends to the 
ribs and lungs, resembling the pains of pleurisy, extending from 
one hypochondrium to the other. This will remind you of my ob- 
servations in the case of the bilious accumulation in Beekman 
street, resembling enteritis ; and that the same cause in other 
cases exhibits the symptoms of pleuritic inflammation. Another 
remark of Pringle, and other practical writers, deserves your at- 
tention ; that when pain and griping exist without much nausea, 
it is an indication that the large intestines are the seat of the dis- 
ease; and on the other hand, that when there is more sickness 
than griping, and the irritation is higher, the disease is pro- 
bably seated in the small intestines — so says Pringle. But you 
will perceive that this distinction must in some respects be equi- 
vocal, depending very much on the sensibility of the nervous 
sj'stem in the individual labouring under the disease. And in 
most cases, too, let it be remarked as a fact, that the disease is 
preceded by indigestion, showing itself in nausea, flatulence and 
eructations, which are to be expected from the costiveness con- 
stituting the commencement of the disease ; but the lower part of 
the intestines becomes the chief seat of its irritations, for there the 
cause of the disease operates with more force, for there is the 
greater malignancy of the contents of the bowels. The con- 
sequences are inflammation, followed by mucous and bloody 
discharges, and sometimes, says Sydenham, no stools at all. It 
is important for you carefully to distinguish between the mucous 
and bloody stools of real dysentery and those attendant upon 
diarrhoea, or which succeed to the use of mercury, or the bloody 
evacuations occasioned by hemorrhoids, and in children by teeth- 
ing. In some cases, too, of dysentery we meet with evacuations 
of mucous without blood ; but this is of so rare occurrence as to 
afford no foundation for the distinction which has been proposed, 
into mucous and bloody dysentery. When stools consisting of 
foeces are procured by art, in this disease, they consist of small 
dry, circumscribed, globular masses, denominated scybala. How 
are these formed ? By the irritation occasioned by the con- 



DYSENTERY. 355 

tents of the bowels producing a spasmodic constriction of the 
intestines, particularly the colon. The same irritation, too, 
excites the absorbents in common with the other parts of the 
vascular system, and occasions the more fluid contents of the 
bowels to be absorbed, leaving the remains hard and dry, and 
moulded in the cells of the colon. In this manner these scybala 
are formed, while the materials absorbed vitiate the whole mass 
and aggravate the character of the disease ; and where the dis- 
ease proves fatal, the intestines being examined after death, are 
frequently found contracted, even in some cases, to three-quarters 
of an inch diameter! — the coats thickened exhibiting ulcers and 
other evidences of inflammation.* 

* See Baillie's Morbid Anatomy, pp. 67—71—73. 



356 



LECTURE XXIX, 



DYSENTERY. 



Having noticed some of the symptoms of dysentery, and 
showed you some of the plates of Dr. Baillie, exhibiting the ulcera- 
tions and changes which the intestines undergo from the infla- 
mation attendant upon that disease, I go on to remark, that in 
most cases of genuine dysentery, the discharge from the intestines 
appears of a mucous and viscid nature, resembling the scrapings 
of guts, or those portions of fatty matter which are separated in 
cleaning the intestines of animals. The thinner parts of the mu- 
cus, the natural lining of the intestines, are absorbed, and the 
more viscid remains are forced off by the tenesmus attendant on 
this disease ; but sometimes the inflammation of the intestines 
produces, as in other membranes of the body when inflamed, 
an excretion of matter, which exhibits a membranous appear- 
ance, and which is . effused on the surface of the inflamed gut. 
We see this process exemplified in the inflammation of the tra- 
chea and pleura, the dura mater, and the intestines in enteritis, in 
strangulated hernia, in the excitement of the uterus, producing 
the appearance of membranes, and in that of the ovum, leading to 
the same deception. See Hunter. 

We see the same in the inflammation attendant upon dysentery. 
By many, this apparently membranous production, the effect of 
inflammation, is considered as the villous coat of the intestines 
thrown off. Not so : this cannot be, except after sphacelus — which 
sphacelus must be preceded by purulent discharges, the effect of 
high inflammation. In those cases, ulcers after death, are ob T 



DYSENTERY. 357 

served to have been the attendants upon such separations of the in- 
testinal coat ; but this apparently membranous matter, which is 
discharged in dysentery, is frequently thrown off, when no ul- 
ceration has taken place in the bowels, as has been ascertained by 
examination of the body after death. This fact is particularly 
stated by Zimmerman. 

Dissections too, show the inflammation of the bowels, which ter- 
minates in ulceration and in sphacelus, are altogether distinct 
from the former. The inflammation has been sometimes found 
to extend even to the stomach, which too, partakes of the gangre- 
nous or dark colour ; the coats of the intestines have been found 
thickened, the villous coat in some cases entirely consumed, and 
the vascular in that case is usually found, loaded with distended 
vessels, and covered with a bloody sanies or slime. The large 
intestines are more frequently found sphacelated and ulcerated 
than the small. Why ? Because they are the residence of 
those more acrid materials which enter into the nature of dysen- 
tery. Inflammation in that part of the intestinal canal is neces- 
sarily the consequence. 

Sometimes too, according to Cleghorn, ulcers are found upon 
the outside of the intestines as well as internally, thereby show- 
ing that the whole texture of the bowels is involved in the in- 
flammation; not only the mucous lining or tissue, but all the 
tissues inside and outside, muscular and peritoneal, as well as the 
inner mucous lining. In some, again, small abscesses were formed 
in the cellular membrane of the peritoneum, contiguous to the 
colon and rectum. In others, the convolutions of the intestines 
were found adhering to each other and to the neighbouring parts, 
as in enteritis. Purulent matter has also been found floating in 
the cavity of the abdomen, and in two cases related by Dr. Cleg- 
horn, the omentum was almost wasted by the absorption of its 
fat ; but in other instances, the omentum has been known to re- 
main loaded with fat, while the intestines had rapidly run on to 
gangrene. In some again, small, flat tubercles, like the flat pus- 
tules of confluent small-pox, are found in the intestines. Pringle, 
Cleghorn, and Hewson, have all noticed these appearances ; and 
Linnaeus has also described what he calls scabies of the intes- 
tines, that he has found in dysentery, and which is probably the 
same appearance. 

31* 



358 LECTURE XXIX. 

Zimmerman too, notices flat aphthae on the intestines, yielding 
pus like the flat pustules of small-pox ; he also remarks, (see Wil- 
son, p. 421,) that the mesenteric glands were found swelled, in- 
flamed, and containing a bad kind of pus. Cleghorn also describes 
scirrhous tubercles, as found after death, in addition to the inflam- 
mation and mortification, which are the attendants upon dysen- 
tery. It is remarked by some writers, that in cases where much 
blood has been discharged during the disease, upon examining the 
body after death, it frequently happens that no ulceration is to be 
perceived, that is, the local inflammation has been removed by 
such discharge. From this fact, Sir John Pringle and Zimmer- 
man have concluded, that the discharge of blood is the effect of 
the typhoid state of the system and the consequent relaxation of 
the vessels, and not the effect of ulcerations or the mere local 
constriction of parts. The truth probably is, that both the local 
and general disease, are concerned in the production of this as 
well as most of the malignant symptoms of dysentery. The 
gall bladder has oftentimes been found much distended with 
bile, and that of a darker colour than is natural, as has been re- 
marked by Cleghorn. This fact shows the want of fresh bile, 
the stricture upon this excretion, and the confined and slow 
state of the bowels, the effect of this diminution of the biliary dis- 
charge. 

Pringle has also given an account of the appearances which he 
met with upon dissection. " Upon opening the body," he ob- 
serves, " even the day after death, the foetor of the gas extricated 
from the body, was intolerable ; the intestines were wholly mor- 
tified, and the stomach partly so ; the very coat of the liver was 
affected, and abscesses had formed in the substance of the liver 
itself, containing purulent and ichorous matter." The spleen, 
he remarks, was likewise found affected by the disease. The 
thoracic viscera generally escape, but a case is related by Mor- 
gagni in his 31st Epist, in which the lungs themselves were 
found very much diseased. Hence then, we see that death is not 
only occasioned by the general febrile state of the system, but 
also by the inflammation which affects the intestines. 

That we may be enabled to form a correct prognosis, let us re- 
count the favourable and unfavourable symptoms of this disease. 
The favourable symptoms are, 



DYSENTERY. 359 

1. Natural stools procured — of proper odour and consistency. 

2. The fever being diminished, the skin becoming moist and 
of its natural temperature, the tongue clean. 

3. Pain removed, or only returning occasionally. When sud- 
denly removed, beware of consequences; i. e. if the sudden disap- 
pearance of pain takes place, attended with cold extremities; not so 
when the extremities are warm. But it should be remarked that 
tenesmus sometimes continues from the remaining increased sen- 
sibility, though the disease itself be chiefly removed ; and indeed 
sometimes a permanent irritability and even strictures, have been 
the consequences. 

Prolapsus ani has also been the result of this disease, when the 
debility of the system has been great, and the tenesmus more 
than ordinarily troublesome. 

The unfavourable symptoms are, 

1. Aphthae in the mouth, is a fatal symptom in general ; for it 
denotes an inflammation of the intestinal coat. 

2. Strictures of the intestinal canal throughout. 

3. Discharges from the bowels of a bloody water, like the 
washings of meat, hence called lotura carnium ; not always 
fatal. 

4. Cold extremities, and a livid appearance of the body. 

5. Stercoracious vomiting. 

6. Tympanites — a fatal symptom ; sometimes vibices. 

7. Carbuncles, as in the plague ; black tubercles. 

Our duty now will not consist merely in procuring the evac- 
uation of natural fceces, and then giving tone to the system 
as enjoined in the indications proposed by Dr. Wilson. Nor is 
our indication that of Dr. Cullen, merely to counteract spasm. 
For in that case opium, which is our most powferful antispasmo- 
dic, would be our remedjr ; on the contrary, in the first stage of 
dysentery, opium is one of the most injurious and dangerous me- 
dicines that can be prescribed. It reminds me of Dr. Under- 
wood's prescription of assafoetida in the cure of another dangerous 
and highly inflammatory disease, the croup. It is a mere pallia- 
tive of a particular symptom, having no regard to the cause or 
leading character of the disease. 

From what we have seen of this disease, as it appears in the 
whole system and in the bowels, more immediately the seat of 
its ravages, we are led to believe that the proximate cause of 



360 LECTTJUE XXIX. 

dysentery consists in a febrile irritation of the typhoid type of the 
whole system, accompanied with inflammation and irritation of 
the intestinal canal, which inflammation is more especially seated 
in the colon and rectum. As the proximate cause is of a two- 
fold character, and as the affection of the intestines is more imme- 
diately dangerous than the general fever, and the local irritation, 
than the typhoid state of the system, our indications of cure will 
also be two-fold, not only to counteract the febrile irritation of 
the whole system, but our attention will also be especially direct- 
ed to the removal of the sources of the irritation which exists in 
the intestines. This irritation consists in inflammation, accom- 
panied with violent spasmodic constrictions of the intestines, 
and threatening sphacelus, a frequent consequence of inflamma- 
tion when seated in organs of great sensibility. 

This inflammation too, is rendered peculiarly dangerous, from 
the materials creating it in the bowels, and those aggravating it 
arising from the state of the whole system. On this account 
then, let your first attention be directed to the removal of the in- 
flammatory and other alarming symptoms affecting the bowels. 
And fortunately, the same means which are calculated to accom- 
plish this object, are also among the best remedies we can employ 
to remove the febrile excitement of the whole system ; but you 
have here occasion, gentlemen, for the best judgment you can 
form in the treatment of this first stage of the disease. You have 
a typhoid enteritis to contend with, and it agrees to typhoid 
peripneumony, or a typhoid inflammation of the throat, or the 
typhoid puerperal fever. 

You have enteritis on the one hand, which calls for active re- 
medies to remove the inflammation ; on the other, the whole sys- 
tem is threatened with typhus fever, the usual form of fever 
attendant upon dysentery, in which antiphlogistic remedies are 
to be employed with the greatest caution. A middle course is 
therefore to be pursued, especially if called upon in the first days 
of the disease, before the strength of the system is much reduced. 
Sydenham and Lieutaud begin the cure of dysentery with 
venesection. See Parr. Dictionary. Akenside recommends it, 
but to be done with caution. 

Dr. D. Monro has also given us a good rule on this sub- 
ject : "where the pulse is feeble, be sparing of the vital fluid." 
Where the habit is full — the subject young and athletic, vene- 



DYSENTERY. 361 

section is certainly not only admissible, but called for in dysen- 
tery; otherwise sphacelus, in such state of body, may be readily 
induced ; and if possible, this remedy when made use of, should 
be employed before the third day of the disease, otherwise it will 
be generally more dangerous than useful. But in a delicate habit 
of body, depressed by the action of the poison on the system, the 
pulse small, feeble, and not indicating high inflammatory excite- 
ment, avoid the lancet, and trust to the other less debilitating 
means of removing inflammation. Leeches, in such cases, may re- 
move the local inflammation. After you have reduced the excite- 
ment by venesection or leeches, when this remedy has been 
indicated, our next attention should be given to the different se- 
cretions of the system. The biliary discharges we have observed, 
are interrupted, and perhaps the gall bladder loaded with a dark 
acrid bile, at the same time that the secretion of fresh bile is in 
some degree suspended by the causes which have been enume- 
rated. Emetics, in such cases, are indicated independent of the 
general febrifuge operation, which is no less in demand in this 
state of the system. Wilson says, do nothing to irritate the 
stomach or bowels ; still he recommends emetics. But although 
they must be irritating to the stomach and inflamed bowels, yet 
the irritation is of temporary operation, and they remove that 
irritation which is more permanent and much more dangerous. 

Pringle, Cleghorn, D. Monro, Cullen, Zimmerman, Blane, 
Lind, and most practical writers, all unite in recommending 
emetics in dysentery. This concurrent testimony too, in favour 
of emetics, is an additional evidence of the connexion which 
exists between dysentery and the derangement of the digestive 
organs. The emetics best calculated for this purpose are anti- 
mony- and ipecacuanha combined ; not the celebrated vitrum an- 
timonii cerusum, recommended by Pringle, for this is, in my 
opinion, an unsafe prescription for general use. Tartar emetic 
affords us every advantage that antimony can give us ; but I prefer 
the combination of ipecac, (grs. xv.) and tartarized antimony 
grs. ij. Sir George Baker gives tartar emetic alone ; Dr. Adair, 
emet. tart, with calomel; Dr. Saunders, emet. tart, with opium. 
Ipecacuanha alone is greatly celebrated, first in doses sufficient 
to excite full vomiting ; (but in my opinion, it is not of itself suf- 
ficient to dislodge the contents of the biliary organs, which in 
the sluggish state in which they are usually found in this disease, 



LECTURE XXIX. 

becomes indispensably necessary;) and afterwards continued in 
small nauseating doses, for the purpose of relaxing the surface of 
the body. Pringle is the great advocate of this medicine. This 
remedy, I believe, was first introduced in dysentery, by Piso. 

Another mode of exhibiting ipecacuanha, has lately been re- 
commended by Dr. Clarke ; (see Observations on the Diseases of 
the East and West Indies, by Thomas Clarke,) that of administer- 
ing it in the form of glyster, 3iij. of the root, bruised and boiled in 
Ibij. of water, to Ifej. ; this to be injected two or three times 
a-day. I prefer the use of it by the stomach, and it frequently 
happens that it also operates upon the bowels as a cathartic as 
well as an emetic, without having recourse to injection. 

The next object is to cleanse the intestines of their acrid con- 
tents. This is to be done by those means that operate most effec- 
tually, but which, at the same time produce the least excitement, 
either to the bowels or to the whole system. With this view the 
saline cathartics are preferred by most practitioners ; they operate 
without creating irritation in the bowels, and relax the system in 
general, promoting the secretions by the skin and the kidneys, as 
well as the intestines. Sulphate of soda, is preferred by many for 
this purpose. Huett's prescription of salts, in combination with 
manna, is as follows: salts, §i., manna, §ij., water, Ibij., half a 
pint every half hour, until two or three stools are procured. 

The practice in the southern states, is doubtless a very good 
one ; that of giving salts in combination with tartarized antimony : 
i. e. where an emetic has not been previously administered, JL 
Glauber salts, §i.; tart. emet. grs. ij. aq. pluv. gviij.; to be given 
in divided doses ; but where an emetic has been given, salts alone? 
in gruel, are to be preferred; indeed, I prefer the more sim- 
ple practice of administering first an emetic, afterwards a ca- 
thartic. 

Zimmerman prefers cream of tartar in combination with tama- 
rinds, as a cathartic in this disease ; but this salt is not suffi- 
ciently active for the purpose for which a cathartic is now wanted. 
When the bowels are freely emptied, it will be an excellent feb- 
rifuge drink, as an auxiliary to more effectual means ; but of itself 
it is not sufficient. Castor oil is also a very excellent and justly 
favourite cathartic in this disease. It is expeditious — it is gentle 
in its operation, yet effectual in unloading the intestines, in doses 
of a table-spoonful and repeated. 



DYSENTERY. 363 

Let me here caution you against the use of rhubarb. Syden- 
ham gives rhubarb with senna or tamarinds; Fordyce, the same ; 
it is valuable in the last stage as a cathartic and tonic. Jalap, aloes, 
and the other stimulant cathartics, from the excitement and pain 
which they create, aggravate the inflammation attendant on dysen- 
tery, and are therefore justly condemned by most practical 
writers. Senna is no less exceptionable for the same reason, 
though combined even with manna, as recommended by Wilson. 

The stimulant additions, frequently combined with cathartics, 
viz. cinnamon and peppermint waters, and aromatic confection, 
as recommended by Thomson, are no less to be avoided in the 
excitement of dysentery. (See his aq. cinn. §ss. combined with 
salts — aq. menth. pip. giiss. in another prescription, and aromatic 
confection in a third: p. 278, last edition.) For the same 
reason avoid tinctures in dysentery; such spirituous compounds 
aggravate the excitement present in the first stage of this disease. 

Let me here call your attention to two sources of deception in 
the use of purgatives. The one is, not to trust the accounts given 
by nurses of the evacuations which may have been obtained ; the 
patient may have had twenty stools, and yet not one. Remem- 
ber, if you have not procured a complete evacuation of the intes- 
tines, you may be very much surprised to find a great flood of 
matter evacuated just before the death of your patient, (when all 
spasmodic constriction of the bowels is taken off,) that ought to 
have been carried off in the first stage of the disease. This fre- 
quently happens where dysentery is fatal, and probably neglect 
in this respect is the great reason of its fatality. Therefore in- 
spect for yourselves; trust only your own eyes in a disease of so 
much importance; it is not usually necessary in the practice of me- 
dicine to inspect the chamber-pot, but in some instances it is indis- 
pensably necessary, as in dysentery, jaundice, constipation. Inquire 
if the scybala we have mentioned are discharged; or at least if na- 
tural faeces, denoting the presence of bile, are evacuated. Do not 
rest satisfied with merely scanty, watery, or mucous discharges. 
Another important direction is, not to purge your patient to ex- 
cess — guided by the offensive smell of his evacuations, which, 
as I have said before, in typhoid fevers, is frequently increased 
instead of being diminished by purging, inasmuch as the digest- 
ive process is impaired, and fermentation of course has an uncon- 
trolled and exclusive operation upon the contents of the intes- 



364 LECTURE XXIX. 

tines. Avoid, therefore, this source of deception, as well as the 
former. Another cathartic medicine frequently used in this dis- 
ease, is necessary, especially in the form of the sub-muriate of 
quicksilver or calomel. It is doubtless a valuable medicine in this 
disease: it not only operates very powerfully upon the biliary 
and other secretions, which take place in the intestinal canal, but 
in addition to its cathartic effects, its operation upon the secretions 
of the system in general, render it a valuable medicine in dysen- 
tery, especially when administered as a sudorific, in combination 
with small doses of antimony, or James' powder or with ipecacu- 
anha; but as a cathartic, I prefer the saline cathartics, or castor 
oil, and afterwards the use of calomel, with small doses of some 
other sudorific, especially where it is desirable to continue the 
evacuation hy the intestines; otherwise the ipecacuanha alone, in 
small doses, is preferable, as prescribed by Sir John Pringle. 
When in the use of ipecacuanha, your patient may make free use 
of the vegetable acids in his drinks, but not when in the use of 
antimony or calomel. 

But in some cases, even this last medicine, administered alone, 
may prove too active to the bowels. It may, then, be more ad- 
vantageously directed in the form of the Dover's powder, where 
such cathartic effect is prevented, and its operation upon the sur- 
face secured. Another means of relieving the surface of the body, 
and of promoting this now desirable determination to the skin, is 
by the sp. mind., especially in combination with laudanum, 
gtt. xxx. or xl. to §iij., a table-spoonful every two hours; or the 
effervescing draught of Riverius may be administered. These 
combinations not only promote perspiration and counteract fever, 
but they allay, in an especial manner, the irritation of the bowels; 
i. e. plentiful evacuations having been previously obtained. With- 
out a moist skin and a soft pulse, Professor Richter observes, this 
disease cannot be radically subdued. His remedies are an emetic, 
laudanum and antimonial wine; and in the advanced stage of the 
disease, rhubarb; but this last he considers dangerous in the com- 
mencement of dysentery. But the irritation of the intestines 
being still continued, (notwithstanding the remedies already di- 
rected,) and this being evinced by an increase of pain upon slight 
pressure, a large blister should be immediately applied over the 
abdomen. Blisters have a double advantage in this disease; they 
not only remove local inflammation, but they diminish the gene- 



DYSENTERY. 365 

ral fever which attends this disease, and should be resorted to as 
early as possible after evacuations have been procured. In a less 
degree of soreness, a warm bath may be advantageously made 
use of, as advised by Sir George Baker, or fomentations of vinegar 
and water, or an application of hops, infused in hot vinegar and 
water, and enclosed in a flannel bag may be laid, of proper tem- 
perature, to the belly; or in case a blister is laid upon the belly, 
the fomentations may still be made use of with benefit, and may 
be applied to the extremities. These last should be frequently 
renewed, and applied at a moderate temperature. But neither 
the w r arm bath nor fomentations should be made use of until the 
first passages have been thoroughly evacuated; for they other- 
wise aggravate the general fever, and render it more malignant 
by the resorption of the offensive contents of the belly. But in- 
stead of a warm bath, or warm applications, Dr. Thomas has ad- 
vised a cold bath, and cold water to be applied to the belly in this 
disease! He certainly has never used it, or if he has, I venture 
to say he has destroyed his patient; for cold bathing, or cold ap- 
plications are assuredly injurious in diseases attended with local 
inflammation. 

In your fomentations to the abdomen, or to the extremities, 
let me also caution you against the use of spirits, pepper, 
and other heating applications, as recommended by Wilson! 
The oil of cloves, the stimulant liniment and spirituous em- 
brocations prescribed by Thomas, are no less to be dreaded in 
the dysentery, as they serve to dry the skin instead of unlocking 
it, and thereby aggravate both the fever and inflammation attend- 
ant upon this disease. There is an application, however, I ob- 
serve, much recommended by Dr. Irvine, in this disease, which 
perhaps, by the great irritation it produces upon the surface, anal- 
ogous to that of blistering, may be useful; I mean the spirits of 
turpentine, applied to the belly, and frequently renewed. That 
author, in his account of the diseases of Sicily, states that he has 
employed it in many cases with benefit. He, however, I per- 
ceive, also attaches great value to blisters in the same disease, and 
they are probably the preferable application on account of the 
greater inflammation they produce. 

The excitement of the system, constituting the first stage of 
the disease, being subdued; the local inflammation being also 
controlled or counteracted by the remedies which have been 
32 



$66 LECTURE XXIX. 

directed, the bowels opened, and the skin relaxed and perspiring, 
the patient still, perhaps, labours under occasional returns of 
irritation about the rectum and anus, but unaccompanied by 
the febrile excitement noticed during the first two or three 
days of the disease. How is this irritation to be arrested or 
removed? and is it safe, while the patient continues to discharge 
blood and mucus, instead of natural evacuations, to arrest them 
by any means? and what are the most effectual means for this 
purpose? Injections may now be had recourse to with advan- 
tage : not stimulant, cathartic enemata, but those which are 
calculated to soothe and remove irritation. For this purpose, oily 
and mucilaginous injections, combined with opium or laudanum, 
are to be preferred. There is a great variety of these in use. 
Mutton soup, prepared by boiling the sheep's head; and, by the 
by, many contend, that to be productive of all the advantages in- 
tended, it should be boiled, wool and all on. Strange as it may 
appear, there is some reason for this; for the wool of that animal, 
near the skin, is covered with a mucilaginous, oily matter, called 
by shepherds the yolk, in which the anti-dysenteric virtues 
probably, in part, reside. Milk and flaxseed tea is another fashion- 
able domestic remedy. An opiate poultice to the fundament 
An opium pill in the rectum. Barley, rice, sago, arrowroot, 
and starch, are all accordingly employed; and are all, or either 
of them, useful. Flaxseed and starch, however, are in most 
general use, §ij. to ^iv. of thin starch, with 3i. or 3iss. of 
laudanum. Dr. Rutherford's preparation of flour, two or three 
handsful, boiled six or eight hours, till hard ; grated, made 
into food, with milk and water, &c. (See Parr. Die.) Great 
care is necessary in administering it, lest it add to the irri- 
tation instead of diminishing it. There is no occasion where 
more depends on the manner in which an enema should be ad- 
ministered than in dysentery; for if thrown up with violence, the 
inflamed bowel will instantly reject it. It should be gently ad- 
ministered, and the pipe as gently withdrawn, that we may awak- 
en as little sensation in the part as possible. This anodyne in- 
jection should be repeated every four hours. It will be proper, 
however, if the least preternatural heat and fever exists, once in 
every twenty -four, or, at most, thirty-six hours, to procure an 
evacuation from the bowels, either by a large, oily enema, com- 
posed of gruel and castor oil, or the ordinary domestic injection, 



DYSENTERY. 367 

or by a repetition of half an ounce of Glauber salts, by the sto- 
mach, or magnesia calcined. The late Dr. Bayley's favourite 
prescription, at this stage of the disease, was four grains of rhu- 
barb, two grains of ipecac, made into a bolus with the Theriac 
Andromachi. Should the typhoid symptoms still be considera- 
ble, or the contents of the bowels unusually foetid, and you have 
reason to apprehend a tendency to sphacelus, an injection of yeast is 
to be preferred to any other form of enema. I must observe that 
opium is not to be directed in any form, by the mouth or injection, 
until the inflammation attendant on this disease, and the general 
excitement of the system have been subdued, or considerably di- 
minished; until you are satisfied that the pain present arises more 
from morbid sensibility than from inflammation, and is out of all 
proportion to the arterial excitement of the system. In this cau- 
tion, Lieutaud, Blane, Pringle, Cullen, all concur. In the lan- 
guage of Zimmerman, " it is always dangerous to give opium be- 
fore the fuel which feeds the disease be burnt out." The lan- 
guage of Huxham and Cullen is no less pointed on this subject. 
The same objections apply to the early use of astringents and 
tonics. There is, perhaps, no practice so fraught with danger as 
the premature use of these remedies. But again, when the first 
stage of the disease is completely passed over, they are not only 
admissible but indicated. Lime-water and milk,* chamomile 
tea,f the Peruvian bark, J oak bark, (Quercus robur,) logwood, 
(haematoxylon eampechianum,) tormentil, (torm. erecta,) marsh 
rosemary, (statice limonium,) simarouba, as recommended by 
different physicians, may be in such debilitated state of the system 
had recourse to ; but remember, when too early prescribed, you 
may expect every dangerous symptom that has been enumerated 
and these, again, will be soon succeeded by the death of your pa- 
tient. They should, therefore, be carefully avoided, while either 
the febrile or inflammatory symptoms continue; and those reme- 
dies should be repeated which are calculated to remove every 

* Dr. Donnald Monro. 

+ Pringle prefers this to lime water. Zimmerman also alleges, that next to 
opium, chamomile tea allays the pains of dysentery. 

I Dr. Whytt preferred the bark, especially where aphthce appeared in the 
mouth, or threatened the alimentary canal. Lime-water and milk is an excellent 
drink in this case. Magnesia, as a laxative, and borate of soda, to the part 
affected. Soda-water, as a drink, is also useful in aphthous affections. 



368 LECTURE XXIX. 

source of irritation from the bowels or the blood vessels; i. e. by 
a continuance of the evacuations from the bowels, and of those 
means calculated to relax the surface, as in the treatment of 
typhus fever, and with the same cautions, observing the different 
grades of excitement. 



THE DIET. 

In the diet of your patient, labouring under dysentery, the 
same attention should be given to the different stages of the dis- 
ease as in the prescription of medicines. In the first stage the 
patient should take plentifully of some thin diluents; and these 
should be taken warm. Toast-water; weak teas, either catnip or 
common tea; water- gruel; barley-water; or even plain water, 
Senac, as Pringle tells us, found warm water the best of all drinks. 
Senac himself, and fourteen of his patients, were the subjects of 
this practice alone, and continued it five or six days, with the 
best effects; but he at last preferred the following treatment: jgr* 
of tart. emet. in a pint of whey or chicken- water, every day 
throughout the disease; making it both the food and physic of the 
patient, until he recovered : it acted both as a cathartic and sudo- 
rific. Baglivi, Huxham, Tissot, Zimmerman and Pringle, all con- 
cur in the necessity and usefulness of plentiful dilution in dysen- 
tery, not only for the purpose of washing out the intestines, but 
indeed the whole system, by the relaxation it produces upon all 
the emunctories of the body. Vegetable nourishments and fruits, 
especially in the beginning, may be given. (Cullen.) Grapes, are 
preferred by Zimmerman. Any fresh fruits are proper. They are 
not only useful in the cure, but in the prevention of the disease; 
not only as antiseptics, but from their effect in quickening the bili- 
ary secretion. Mucilaginous nourishments are also peculiarly pro- 
per in this disease, not only as nourishments, but as calculated to 
sheath the intestinal canal from its acrid contents. For this pur- 
pose sago, cycas revoluta and circinalis, arrowroot, maranta arun- 
dinacea, salep, orchis mascula, rice, oryza sativa, barley, hordeum 
distichon, pearl barley, rendered pleasant by raisins $ tapioca, jat- 
ropha manihot and janipha, cassava or cassada boiled with it; 
flax-seed tea, linum usitatissimum, are among those to be pre- 
ferred. All writers on this subject, agree on the bad effects, 



DYSENTERY. 369 

of animal food. They add to the septic state of the bowels, 
and of the whole system. Baker, Pringle, Zimmerman, D. 
Monro, are all opposed to it in every shape, even in the form 
of soups. " Not even chicken soup," says Sir George Baker, 
"should be allowed in this disease," u nor mutton broth," 
says Pringle. Akenside, however, to our great surprise, we find 
recommending animal food, even in a solid form; beef-steaks in 
a dysentery, animal food in typhus fever! I should rather consult 
him as a writer on the pleasures of the imagination than follow 
his directions in dysentery. Another fashionable prescription, 
much in use, is mutton suet, boiled in milk, with cinnamon and 
loaf-sugar. This is not admissible in the first stage, but the good 
women of our city, finding it good in the last stage of dysentery, 
conclude that they cannot begin too soon, nor have too much of a 
good thing. In the second stage, let me observe that vegetable 
nourishments should still be continued; but that they may now be 
advantageously given with wine; or if the stomach be inclined to 
acidity, with a moderate quantity of brandy. But recollect, that 
by giving these articles too early in the disease, you introduce so 
much fire into the already inflamed intestines. 

Attention to regimen in this disease is no less important than 
is our prescription of medicines, or directing the diet of your pa- 
tients. Inasmuch as dysentery is propagated by means of the 
excrementitious discharges, there is no rule more important than 
that these should be instantly removed from the chamber of the 
sick. Another direction in this case should be that the alvine 
discharges particularly, should not be thrown in the common 
privy, but buried ; for privies, it has been observed by all writers, 
become the principal means of spreading the disease throughout 
the family or the camp wherever it may occur. With the same 
view, the clothing of the patient should be frequently changed ; 
both that which constitutes his bedding as well as his bodily 
clothing ; and let me add, that flannel worn next the skin consti- 
tutes the most proper dress of the patient in this disease, as well 
as the greatest security in guarding those who are well against an 
attack of it. Dewar, in his observations on dysentery, particu- 
larly recommends a swathe of flannel to preserve warmth about 
the abdomen, and to give support to the weakened bowels. 
There is perhaps, no one direction in the treatment of dysentery 
to which he attaches more value than to this application, alleging 
32* 



370 LECTURE XXIX. 

that he has ever found it attended with the best effects. But not 
only the clothing, the bed and the bedding should be frequently 
changed and aired, in this disease ; and the air itself of the apart- 
ment should also be frequently renewed, and all noxious mate- 
rials removed as far as ventilation and the disinfecting processes 
can effect such changes. I need not repeat the processes em- 
ployed for this purpose, which have been so fully detailed to you. 
Having removed the inflammation and other sources of irritation 
from the bowels, and having obviated the general fever, you have 
now a second indication — to build up the strength of your patient 
by means of tonic medicines and such system of diet as will be best 
calculated to counteract the debility that has been induced. The 
bitter infusion with the addition of the carbonate of potash or 
soda, and a small quantity of rhubarb will be peculiarly calculated 
for this purpose — they are among your best tonics. Madeira 
and Port wines are also now to be allowed the patient, and that 
freely in proportion to his weakness. Dr. Brocklesby allowed his 
patients ibiss. to be taken daily if necessary. Dr. D. Monro di- 
rects brandy and water to be taken, if the use of wine should be 
followed with acidity or pains in the bowels — an excellent direc- 
tion. The patient, too, should return gradually to the use of ani- 
mal food. As there still remains more or less of the typhoid 
state of the system, he should still continue the use of the vege- 
table nourishment in part, and when soups are first made use of, 
let a large proportion of vegetables enter into their composition, as 
rice, celery, &c ; but if the stomach be especially debilitated and 
there exists a great tendency to fermentation of its contents, animal 
food in the solid form is to be preferred, followed with a glass of 
brandy and water — steadily continuing the use of the bitter infu- 
sion, or perhaps as recommended by Dr. Whythe, an infusion of 
bark may be now advantageously administered in conjunction with 
the Japonic confection 3iij., or the R. of kino, §ss., to Ibi, of the in- 
fusion. The infusion of bark with lime water is also in some cases 
preferable. But perhaps your patient has lost a great deal of 
blood by hemorrhage — his bowels remain in too relaxed a state, 
or upon falling asleep, such is his debility that he sweats pro- 
fusely — astringents in such cases are indicated. With this view 
an infusion or decoction of the bark with the addition of the 
elixir of vitriol, may be given the patient. Some direct the 
nitric acid, as in the following prescription, or a combination of the 



DYSENTERY. 371 

nitric and muriatic, viz : gtt. ii. of the nitric, gtt i. of the muriatic, 
with laudanum, proportioned to the irritation. See Good, vol. ii. p. 
470. Nit. acid 5ij., opii. gr. ij., aq. font. ^iij. M.; a tea-spoonful 
every three or four hours, in any vehicle, say Port wine. By 
the by, in such cases, pert wine too, or even spiced with cinna- 
mon, is to be preferred, for the purpose of restraining the ex- 
cessive discharges to which the patient is yet exposed. And in- 
deed it may still be necessary to have recourse to an opiate mu- 
cilaginous enema to allay the local irritation which may remain 
in the lower bowels — for tenesmus not unfrequently remains af- 
ter the disease has been subdued and the patient is convalescent. 
I have occasionally been obliged to have recourse to some means 
of this kind to quiet the irritations which thus remain. In some 
instances I have done this by a small quantity of paregoric elixir 
— by a pill of opium and ipecac, say one-quarter of a grain of 
opium, and gr. i. of ipecac, or a pill of opium introduced into 
the intestine as a suppository. But in other cases, instead of ex- 
cessive discharges there is a tendency to a confined state of the 
bowels. You should be no less attentive to obviate this state of 
things either by a mild cathartic injection, or some mild aperient 
taken by the stomach, with this view. Small doses of rhubarb 
and magnesia, with mint water, may now be administered in 
divided doses, for the bowels neglected, a putrid colluvies will 
soon be formed in the lower intestines, and a renewal of the in- 
flammation may soon be expected as the consequence. As soon 
as the patient is enabled to take exercise, and the weather will 
allow him to leave his chamber, his recovery will be very much 
hastened by the stimulant effects of the open air. Where ulcera- 
tions have taken place in dysentery, the turpentine and the bal- 
sams have been recommended on account of their stimulant effects. 
It is plain they can only be admissible in the last stages of dysen- 
tery, and that they can only be useful where you have the evi- 
dence of such ulceration having taken place, and that more or 
less purulent discharges are still continued denoting this ulcerated 
condition. 



372 



LECTURE XXX. 

FEVERS.— PLAGUE, OR PESTIS ORIENT ALIS. 

Under the present system of quarantine laws, which the legis- 
lature of this state in particular, in their wisdom have adopted, 
while they continue to be faithfully executed, we shall probably 
never have occasion to prescribe for the plague. Still it is pos- 
sible, from the -commercial character of our country, that we may 
be visited with this form of pestilence, as we have been by the 
yellow fever and other contagious diseases. The late prevalence 
of this disease, on the coast of Barbary, with which we hold 
communication, ought to prepare us to expect a visitation of this 
nature; and our government, in its quarantine regulations, should 
ever keep this event in view — for a chest of clothes of a person 
dead of the plague, introduced into any part of our cities, would 
infallibly spread the disease as it has done in different parts of 
Europe; and the utmost vigilance, with respect to that source of 
it ought, in the increasing intercourse we are cultivating with that 
quarter of the world, to be exerted by all concerned in the re- 
sponsible station of guarding against the introduction of foreign 
diseases. It is important, then, that the physician should become 
acquainted with this disease, not only because it is a reproach to 
be ignorant of it, but because it is possible that he may want his 
knowledge of it at the bedside, should accident so introduce it. 
It will at least be useful for us to know the peculiar characters of 
the plague, as it is calculated to reflect light upon those general 
principles that we have endeavoured to impress upon your minds 
with regard to the nature and treatment of contagious diseases in 
general. 

Dr. Cullen defines the plague to be " typhus maxime conta- 
giosa cum summa debilitate — incerto morbi die eruptio bubonum 



PLAGUE. 373 

vel anthracum." But Dr. Cullen, on account of these buboes and 
carbuncles, and perhaps the petechia attendant on this disease, 
has very improperly placed pestis in his order of eruptive dis- 
eases. He might, with equal propriety, have placed typhus 
among his cutaneous diseases. As the plague is attended with 
general fever, and is naturally allied, in many of its features, to 
many other forms of fever we have noticed, I have placed it in 
the class of fevers properly so called. The first source of this 
disease, like smallpox, syphilis and others, is not yet developed. 
It is well known, however, that it has long infected the western 
parts of Asia, from the thirtieth to the forty-second degree of 
north latitude. The Carthaginians were afflicted with it at least 
two thousand three hundred years ago. Thucydides has described 
the plague which wasted the city of Athens two thousand two 
hundred and eighty years since. Procopius mentions a plague 
which appeared in the five hundred and fortieth year of the Chris- 
tian era, and which is stated to have threatened the very destruc- 
tion of the human race. At that time it was not confined to one 
spot, nor to one season of the year. It is said to have spread in 
the winter as well as in the summer, and to have spared no situa- 
tion, "neither island, cave, or mountain," says the historian, — 
(Williamson in Med. and Phil. Reg. vol. i. p. 28.) It is, how- 
ever, remarkable that it did not prevail in Egypt, which many 
call its birth-place, during the greatest population and splendour 
of that part of the world, and when it was governed by its native 
princes; and when, too, it contained larger cities even than Cairo; 
it was then proverbially a healthy country. Herodotus gives 
pointed testimony on this subject. He says, " After the Africans, 
no people are to be compared with the Egyptians, in health and 
vigorous constitution." And to this advantage he adds, "the 
climate, which is subject to no variation, may effectually contri- 
bute." But when the Egyptians came under a foreign yoke, 
their character changed, their enterprise destroyed, their canals 
neglected and obstructed, the consequences were, collections of 
stagnant water, and the air loaded with mephitic vapours; their 
country, as was to be expected, whether we consider this state of 
the air to operate as a predisposing or an exciting cause, became 
the seat of pestilence. 

In 1346, a plague began in the northern parts of China, spread 
through Asia, crossed into Europe, by way of Constantinople; 



374 LECTURE XXX. 

from thence it traversed Greece, Italy, Germany, France and 
England. Indeed, since Marseilles, which is in the forty-third 
degree of north latitude, began to trade to the coast of Asia, it 
has been visited at least ten or fifteen times with the plague. 
England also, since she has engaged in the trade of the Levant, 
has suffered frequently from that deadly disease. Even the Rus- 
sians, when at war with the Turks, introduced it into their north- 
ern climate by means of goods that had been brought from the 
infected cities of their enemies. It accordingly spread in Mos- 
cow in 1771, although that city is in the fifty-fifth degree of 
north latitude! It has, therefore, as you perceive, not been con- 
fined to the eastern hemisphere; and indeed, in some countries of 
the east, as Persia and Japan, it was altogether unknown; and I 
believe they still remain exempt from the visitations of this dis- 
ease. For a more full history of this disease than my time will 
allow me to give you, I must refer you to authors — Mead, Sy- 
denham, the two Russell s, viz. John, the author of the History of 
Aleppo, and Patrick Russell's History of the Plague; Merten's 
Plague of Russia, and Samoilowitz, a Russian physician ; Dr. 
Guthrie, on the same subject; Assalini, on the Plague of Egypt; 
Volney, Desgenettes's Memoirs; Sir Robert Wilson, Savery, 
McGregor's Sketches of the Expedition from India to Egypt; 
Sonnini's Travels into Greece and Turkey, and Dr. Williamson's 
Observations, contained in the Med. Register, will furnish you 
with ample materials on this head. Dr. Cullen has called the 
fever attendant on plague, the typhus form of fever. True, it has 
many symptoms which would entitle it to that appellation, but it 
has other symptoms which give it a totally distinct character, and 
which, in my opinion, constitute it a distinct genus. Besides its 
general febrile symptoms, it is characterised by the presence of 
buboes and carbuncles, which are its general attendants, as you 
will find upon consulting the works before referred to, especially 
the valuable and elaborate work of Dr. Patrick Russel. "Of 
2700," says Dr. Russel, "afflicted with plague, 1841 were affect- 
ed with inguinal buboes; of the same number, 569 axillary; 231 
parotid; 74 spurious; and 490 carbuncles." I ask you, is this 
typhus fever? Is this bilious remittent? And I ask, will you 
call him a physician that can confound plague with those diseases; 
or who can pronounce plague to be the yellow fever? For in 
yellow fever, none of these characteristic symptoms of plague are 



PLAGUE. 375 

to be found among its usual attendant symptoms. For these rea- 
sons I have made the plague a distinct disease from every other 
form of fever; though it must be acknowleged it bears a much 
greater resemblance to the yellow fever of the tropics than to any 
other species or genus of fever. 

The invasion of this disease is like some other contagious dis- 
eases, frequently sudden and violent. And in some cases, the per- 
son attacked drops as instantaneously dead as if he had been shot 
with a musket ball. In many writers on this disease, when it 
has been epidemic, it is stated that persons have been found dead 
in the streets — so of yellow fever. In other cases, so violent is 
its operation on the system, that they perish within twenty-four 
hours from the time of the attack; but most generally the disease 
is of several days continuance. In some cases it has continued 
to the thirteenth, and even to the seventeenth day. Its duration, 
however, is uncertain, depending upon the character and progress 
of the local symptoms, which we have observed to characterise 
it; viz. the buboes and carbuncles. Buboes, in some cases, ap- 
pear very early, and suppurate early. In such cases, the disease 
is rendered comparatively mild and of short duration. Where 
they are late in their appearance, the disease exhibits a more for- 
midable character, and is at the same time more tedious. Carbun- 
cles, again, are, for the most part, the attendants upon the ad- 
vanced stage of plague, and arise from the vitiated state of the 
system belonging to that period of the disease, in addition to the 
exhaustion of the vital powers induced by the poison engen- 
dered by the disease. On both these accounts, then, carbuncles 
in plague are considered as more alarming and dangerous symp- 
toms than buboes. Petechia?, too, arising from the same source, 
appear in this, as in other typhoid forms of fevers. Some 
physicians, seeing these facts, have been induced to make a divi- 
sion of the disease into species, according as buboes, carbuncles 
or petechia?, are predominant symptoms; but such distinction is at 
least useless, if not absurd; for it is with the plague(see Thomas, 
p. 234,) as with other febrile diseases. Its character is very much 
changed by the circumstances of season and situation, as well as 
the habit of body in which it occurs. Accordingly, in Dr. Rus- 
sePs practice, you will find many varieties noticed as arising 
from the operation of these causes; and in Sir J. McGregor's 
Sketches of the Expedition from India to Egypt, you will also 



376 LECTURE XXX. 

see the character of the disease very much changed by the state 
of the air, whether it occurs in the crowded hospital or in marshy 
grounds, or in the cold, rainy months of December and January, 
assuming the more malignant, remittent and inflammatory charac- 
ter. The vital functions, in plague as in yellow fever and other 
diseases arising from contagion, show the deleterious operation of 
the poison producing the disease. The pulse is sometimes, from 
the commencement, very small and feeble; in other instances, it 
is remarkably slow; while again, in other cases, the pulse, as in 
yellow fever, is very little changed in any stage of the disease; 
i. e. the poison of the disease fastens on other parts of the sys- 
tem, and therefore affects the heart and arteries less. Respiration 
partakes of the same influence. It is frequently attended with 
great anxiety, despair and depression; and these symptoms, as in 
yellow fever, are generally considered as fatal symptoms; espe- 
cially if they appear in the commencement of the disease. The 
tongue, as in other contagious diseases, is frequently moist and 
natural throughout the whole progress of the disease; but in other 
cases it is slightly furred. The thirst, in some cases, is great, but 
in others it is not remarkable. The skin is usually described as 
dry and parched, in some cases moist; but when moist, it affords 
a favourable prognosis. The perspiration has been remarked to 
be oftentimes foetid to a very great degree in this disease — pro- 
bably owing to climate as well as the character of the disease 
itself. The same is observed of the breath of the patient, that it 
very soon manifests an uncommon fcetor, attended with great 
nausea, and sometimes a vomiting of dark bilious matter. In some 
cases an irrestrainable diarrhoea takes place, and soon hurries off 
the patient. Hemorrhages are also of frequent occurrence in the 
plague; and, as in other fevers of a typhoid type, they are gene- 
rally considered at least as dangerous, if not fatal symptoms. 
They take place from the nose, gums, stomach, liver and bowels, 
as in yellow fever. But the black vomit, I mean the coffee-ground 
black vomit, one of the characteristic symptoms of the yellow 
fever, is scarcely known to occur in the plague. 

Buboes usually appear on the first, second, and third days — of- 
tentimes on the first day — and when proceeding early to suppu- 
ration, they are among the favourable symptoms. They probably 
direct the excitement of the whole system to a particular part, 
less dangerous than when the same irritation is expended upon 



PLAGUE. 377 

the other parts of the frame, and especially upon the vital func- 
tions. Buboes, under any circumstances, are considered by Dr. 
Guthrie and others, as less alarming and less fatal than carbuncles, 
and for the reasons we have already assigned. Indeed, carbun- 
cles and petechias are both unfavourable symptoms in the plague; 
for carbuncles, when they prove fatal, become gangrenous, as- 
suming the usual malignant aspect of the anthrax, properly so 
called. And it is also observed in plague, that petechias and ma- 
culae, or ecchymoma, frequently turn to carbuncles — so says Sa- 
moilowitz in his Account of the Plague of Russia in 1771. See- 
ing this malignant train of symptoms to attend upon the plague, 
you will be prepared to believe that it is one of the most fatal 
diseases of mankind. Of the French arm}^ that invaded Egypt, 
according to the Report of Desgenettes, the chief physician to that 
army, but little more than one-third of all that took the disease 
recovered. 

This leads me to a remark or two relative to the causes of 
plague. This disease, until very lately, was universally admitted 
to arise from, and to be propagated by, a peculiar contagion. It 
is also generally remarked to show itself about four days after ex- 
posure to persons labouring under it, or after a similar exposure 
to infected goods. The infection, too, is generally limited to a few 
feet, and is communicated chiefly by contact, or very near ap- 
proach to the source of the infection. In this it is unlike other 
contagious diseases. Warm weather is considered to be favour- 
able to its progress. Cold, on the contrary, is unfavourable to its 
increase. Sometimes, however, like typhus fever, it continues 
throughout the winter. Sometimes, too, it is checked by great 
heat. In all the plagues of Aleppo, of the last century, it has al- 
ways ceased in the months of August and September; i. e. dur- 
ing the greatest degrees of heat. Sonnini (Travels, p. 255,) ob- 
serves " that the contagion of the plague never failed to cease at 
once at the summer solstice." It is only during a season of 
moderate heat that it has ever been observed to prevail exten- 
sively. In Europe it has invariably raged most violently and 
fatally in the summer and autumnal months, especially in Sep- 
tember and October. In the plague of London, of 1665, the 
deaths from the plague were most numerous in August, 20,046 ; 
September, 26,230; and in October, 14,373; but ceased altogether 
with the winter's cold ; for the cold weather of northern climates 
33 



378 LECTURE XXX. 

has invariably been observed to check the ravages both of the 
yellow fever and the plague. On the contrary, however, as I 
have just remarked, the extreme heat of southern latitudes is 
equally adverse to the propagation of the contagion, so that the 
disease is, in fact, unknown in tropical climates. In Egypt and 
Syria its progress is always suspended during the hottest months 
of the year. This too, is a strong diagnostic between it and yel- 
low fever. As in yellow fever, infants are less liable to it than 
adults; but even those at the breast are not exempt. The 
poison of plague, also, like that of the fever, is communicated 
to the fetus in utero, for children are born with the sores of 
plague on their bodies; and added to this, the plague is generally 
fatal to pregnant women. 

That the plague is not known to arise spontaneously any where, 
but is always to be traced to contagion; and that the distance to 
which its infection extends through the atmosphere is very small, 
are established by general agreement. 

Some particular persons, in a most remarkable manner, escape 
this disease, as is peculiarly the case with attendants on the sick, 
the effects of habit, yet we know, in many instances they 
have no immunity or exemption from its attack. According to 
Sir. J. McGregor, of thirteen physicians, seven took the disease, 
and four of the seven died of it; and in the plague of Marseilles, 
which we have noticed as recorded by Bertrand, confessors, phy- 
sicians, nurses, all took the infection. (See my paper on Conta- 
gion. ) This disease, too, as we have already seen, in the cases 
of Matthias Deggio, as related by Dr. Guthrie, Dr. "White, no- 
ticed by Sir Robert Wilson, the Russian surgeon by Sonnini, 
and by Mon. Eusebius Valli, is communicable from one to an- 
other by means of inoculation, which abundantly demonstrates 
the fact that the plague, although it is governed by the laws be- 
longing to my third class of contagious diseases, is still a disease 
sui generis. But in addition to this cause, viz. contagion, as a 
mean of propagating the disease, it is also stated, that other agents 
operate in the production and propagation of it in its native coun- 
try; viz. putrid animal and vegetable substances; noxious exhala- 
tions from the slimy deposits of the Nile, crowded and confined 
dwellings, want of cleanliness, bad diet, either from damaged 
grain and other provisions, or the excessive use of animal food. 
A moist state of the atmosphere, according to Sir Robert Wilson, 



PLAGUE. 379 

is also considered among the causes favourable to the production 
of this disease. He adduces two facts in confirmation of this ob- 
servation; the first is, that the English and Turkish armies that 
marched to Cairo escaped the contagion, though they passed 
through many villages that were infected with it ; while the 
troops that remained stationary on the shores of Aboukir, ex- 
posed to a moist air, were severely affected, and lost many men. 
The second fact is, that a dry air operated to prevent the disease; 
and indeed, in one instance, it appeared to act as a remedy, after 
the disease had commenced. He accordingly states, that several 
men who were ill of the plague in the hospital at Jaffa, escaped 
into the desert, and endeavoured to reach the army ; but not suc- 
ceeding, they returned in three days, perfectly recovered! Those 
too, who were exposed to vicissitudes of heat and cold, w T ere re- 
marked to be more liable to, and to suffer most from, the plague. 
Accordingly, bakers, smiths, and cooks, were noticed during the 
late campaign to Egypt, to suffer most from this disease. 

Mr. White, although he contends that the plague is never in- 
troduced by contagion, has the following remark. " None con- 
tend that the plague is not like all fevers, more or less infectious, 
according to habit of body and duration in bad air; but that the 
disease hangs only in the atmosphere, or breath of the immedi- 
ately affected patient, not to be conveyed by touch on a third per- 
son." (Expedition to Egypt, p. 253.) He also acknowledges 
his embarrassment in accounting for the " partial infection of at- 
mosphere, which at present can only be attributed to the different 
degrees of fetid matter left on the ground, producing the quan- 
tity of putrid miasmata." But this difficulty vanishes if we ad- 
mit the classification we have proposed, and the laws of commu- 
munication to differ with different classes. No wonder Mr. 
White remarks, that the problem is arduous, that if the plague be 
contagious, and not like the small-pox, to be had only once in a 
life, how, in a country where no care is taken to check the exten- 
sion, population has not long since become extinct, p. 255. 

But for the reason that the plague is not small-pox, we should 
expect it to be governed differently. 

TREATMENT OF THE PLAGUE, 

In the treatment of the plague, we shall find that there is no 
less resemblance to the yellow fever, than we have observed in 



380 LECTURE XXX. 

many of its symptoms. In some cases, according to Dr. Russel, 
the lancet was found to be very useful ; while, in others, it was a 
dangerous and fatal practice. In the hands of Dr. White, it 
proved fatal to all upon whom he employed it ; but Dr. Russel 
remarks, that when employed early in the disease, a plentiful 
bleeding is of very great service. Most writers, however, advise 
this remedy to be cautiously and sparingly employed ; and when 
employed, that it should be in the invasion of the disease. It is 
a good rule in this, as in the yellow T fever, " to avoid extremes." 
Emetics are also, as in many other fevers of the typhoid charac- 
ter, considered as very useful ; for the stomach is not in plague, 
as it is in the fever, the seat and throne of the disease ; on the 
contrary, the patient in the plague not only bears the operation of 
vomiting, but it is absolutely necessary, for in this disease it fre- 
quently happens, that there is a very diseased condition of the 
stomach, biliary organs, and intestinal canal ; this is evident from 
the nausea and vomiting, and bilious discharges, which appear 
upon the invasion of the disease. Dissections, too, have disco- 
vered the gall bladder to be loaded with a dark coloured bile, and 
attended with an obstruction and enlargement of the liver itself. 
Cathartics are also indicated, but most writers concur in recom- 
mending the mildest to be made use of in this disease ; alleging 
that diarrhoea is always dangerous : — laxatives, injections, and 
suppositories, are accordingly preferred to active purges ; and 
when diarrhoea supervenes, the most active astringents with 
opiates are industriously made use of to restrain it. But of all the 
means made use of to control the violence of the plague, and to 
divert its ravages from the vital organs, is sweating. This, whe- 
ther it takes place spontaneously or is induced by art, is found to 
be beneficial in this disease. I mean, when induced by those 
means that do not add to, instead of diminishing the excitement of 
the system ; for, doubtless, we will all agree with Dr. Falconer, 
of Bath,* that the sweating regimen as formerly practised by hot 
drinks, heated rooms, feather beds, and loads of bed-clothing, has 
been, and must be, a fatal practice, in any fever. Yet it does not 
follow, as Dr. Falconer has inferred, that because the patient, 
noticed by Savery, who tied himself on the deck, exposed to the 
dews and cool night air, recovered from a severe attack of the 

* Essay on the Plague. 



PLAGUE. 381 

disease; or because the French soldier, recorded by Desgenettes, 
threw himself into the iMile, and also recovered ; that therefore 
every patient must do the same, or that Dr. Curries' cold water 
treatment must, in all cases, be pursued : on the contrary, I be- 
lieve such practice to be dangerous in the extreme, in any febrile 
disease, where either the disease itself has been caused by a poi- 
son, originally introduced, or where the disease, whatever may 
have been the cause of it, exhibits, in its progress, the vitiated 
state of the whole system. In either of these cases, as I have 
very fully stated, the process of perspiration is peculiarly salutary: 
1, by diverting the excitement from the vital organs ; 2, by con- 
veying out heat ; and 3, by carrying off those morbid materials 
which, in health, are constantly passing off, and which, retained, 
must necessarily aggravate the already diseased condition of body 
that attends on fever, especially fevers arising from contagion : 
and that, therefore, this cold regimen, which restrains or checks 
this important discharge, must be injurious in the manner recom- 
mended. It is in confirmation, too, of the benefits that are derived 
from perspiration in the plague, that the practice of rubbing the 
body with warm oil has been so universally and so successfully 
employed in this disease, as stated upon the authority of Mr. 
Baldwin, the British Consul General in Egypt ; you will also 
see an account of it in Dr. Duncan's Med. Com. for 1797. In 
this account you will perceive, that it is not from any virtues con- 
tained in the oil, but the perspiration induced, that proves so 
beneficial ; and, indeed, the whole manner in which it is to be 
made use of is calculated to effect such perspiration. The patient 
must be in a warm room ; he must be briskly rubbed, and, as 
stated, for the purpose of producing a profuse sweat, he must take 
warm sudorific drinks, such as elder flower tea ; he must, too, be 
exposed to the fumes of juniper berries and sugar to aid it ; and 
every precaution is employed to prevent cold from checking his 
perspiration ; his linen must not even be changed, until his per- 
spiration has subsided, and, indeed, the friction is directed to be 
repeated ; all these show clearly the manner in which the oil is to 
operate. The same good effects from this application are noticed 
by Assalini,who also ascribes its salutary operation to the copious 
sweating it produces. During the prevalence of plague in West 
Barbary, in 1799 and 1800, Mr. Jackson, in his account of the 
Empire of Morocco, states, that it was also very successfully em- 
ployed. 

33* 



382 LECTURE XXX. 

But it is observed that it has a salutary effect in preventing the 
disease, as well as curing it. The same writers allege, that the 
dealers in oil, as well as those who are employed in rubbing the 
sick, escape the disease ; that even the porters and labourers who 
work in the oil stores are exempt from its attack. I rather sup- 
pose, that the exercise of these men, by the steady perspiration 
such labour produces, in part preserves them from the influence 
of contagion ; for in the great plague of London, it was observed 
that those who were dealers in pitch, tar, and tobacco, also escaped 
the contagion ; probably, upon the same principle, but not that 
those articles furnished any peculiar antidote to the poison of the 
disease. In like manner, the application of oil has been found 
serviceable in the yellow fever of the West Indies ; but long be- 
fore the introduction of the oil as a remedy, the sudorific treat- 
ment, as recommended by Dr. Warren, was found no less success- 
ful. The best means of preventing the operation of contagion, if 
the observation we have already made on this subject be correct, 
will be cleanliness, ventilation, and purifying the air, by the 
processes pointed out, by means of the nitric, muriatic, and acetic 
acid gases. 



383 



LECTURE XXXI. 



YELLOW FEVER.* 



On the yellow fever I have few observations to make to you ; 
for I have so frequently, in the course of our remarks on fevers 
in general, had occasion to refer to this subject, that to dwell at 
this time on this topic, would be to repeat at least much of what 
has already been said. I shall therefore, in a very summary 
manner, call your attention to the leading features of this disease, 
the causes from whence it arises, and that mode of treatment 
which has been found most successful, especially in the United 
States. Typhus icterodes cum flavedine cutis, is the definition 
given of the yellow fever by Dr. Oullen. But this yellowness of 
the skin combined with typhus, does not alone constitute the 
characteristic symptoms of the disease when it proves fatal ; for 
besides this yellowness there is very generally, on or about the 
third day, not before, more or less disturbance of the stomach or 
biliary organs, showing itself in the vomiting of black matter. 
This is indeed so generally attendant on the malignant form of 
the fever, that the Spaniards thence call it the vomito prieto, or 
black vomit, from the frequent presence of this symptom, espe- 
cially when the disease terminates fatally. This appellation of 
black vomit is therefore quite as appropriate as yellow fever ; for 
where the disease is early arrested in its progress, and the excre- 
tions are steadily kept open, such yellowness is frequently pre- 

* I retain the term yellow fever, for as Dr. Willan observes of scarlet fever, 
" however offensive the term may be to a classical ear, it cannot well be dis- 
placed, having found admission into all the systems of nosology." Page 253, 
Diseases of the skin. 



384 LECTURE XXXI. 

vented. A definition of the yellow fever ought, therefore, to 
embrace more particulars than Dr. Cullen has included, other- 
wise we should be at a loss to distinguish it from jaundice, which 
in some cases proves fatal, and is rendered so by the typhoid 
symptoms that occasionally attend on that disease, as in the 
cases already referred to. In like manner we should mistake 
other diseases of the liver for the fever, that is, judging merely 
from the colour of the skin. We should also in other cases, 
confound it with the bilious remittent — whereas, the state of 
the stomach and biliary organs enables us very readily, for the 
most part, to separate those two diseases. In the first place I re- 
mark, that the yellow fever, as far as regards its origin, is a disease 
peculiar to the tropics, or those climates which experience the 
heat of the tropics, both in degree and duration. But it is occa- 
sionally conveyed into higher latitudes, where, like the fruits and 
other vegetable productions from the tropics, it is preserved and 
even propagated in the hot seasons of the year, that is, while the 
heat remains at, or nearly at that temperature which gave it birth. 
But again, as the tropical fruits are destroyed by the cold of win- 
ter, so is the yellow fever extinguished by frost. It has accord- 
ingly appeared at various times in the south of Europe, and in 
various parts of the United States. But it has invariably, in 
those cases, been introduced from the tropics, and then usually 
from the West Indies, or from South America. I shall also then 
have an opportunity of showing you that the fevers which pre- 
vailed in the Greek islands, and the dark coloured vomiting, as 
described by Hippocrates, were totally different from the yellow 
fever with which they have been confounded by a learned physi- 
cian of this city, in his report lately published on this subject. I 
shall also take the same occasion too, to satisfy you that the same 
writer has been hastily led on to similar errors, when he con- 
founds the yellow fever with the fever hemitritsea of Baglivi, 
generated by the marshes of the neighbourhood of the city of 
Rome. The very direction given by Baglivy, that the patient is 
not to take a purge until the seventh day of the disease, should 
alone have prevented him from falling into this error. It has 
also been engendered on the coast of Africa, as was the case in 
1793, during the memorable expedition to Sierra de Leone. On 
this occasion it first appeared in the ship Hankey, and such was 
the mortality that it created in the crew of that ship, and those 



YELLOW FEVER. 385 

concerned in that voyage, that it totally defeated the objects of 
that expedition. The Hankey proceeded to the island of Gre- 
nada. The disease immediately spread with great mortality, 
not only in that island, but extended itself to the other islands. 
It was in that same year, too, introduced into Philadelphia. Dr. 
Chisholm has given you a record of its ravages, in his very able 
and instructive work on the pestilential fever as it appeared in 
Grenada, &c. ; and which you will consult with great pleasure 
and instruction — pleasure as it regards the manner in which it is 
written, and instruction from the matter which it embraces. It 
affords the best evidence of the correctness of Dr. Chisholm's 
views, that the Board of Health of Great Britain, when they in- 
vestigated the subject, ordered that ship to be burnt, which was 
accordingly done. 

2. In the tropics, too, the yellow fever is not generally a dis- 
ease of the natives, but of strangers, and particularly such as 
arrive from the north, who have been unaccustomed to the in- 
tense heat of the tropics. It may be called then, a disease of the 
northern man in the torrid zone, and to which he is especially 
liable upon his first arrival. 

3d. This disease shows itself in various grades, depending on 
particular circumstances, as upon the state of the air, habit of 
body, previous modes of life, intemperance in drinking, excesses 
in eating, bad provisions, particularly the excessive use of salted 
provisions. In the insulated individual it will exhibit one cha- 
racter, but in a congregation of soldiers or sailors, it will show 
another. Hence, too, in the one case the disease terminates with 
the individual, as was the case with young Roe ; but in the other 
the impurities of the air add to its malignancy and render it com- 
municable from man to man in the manner that has already been 
particularly pointed out. 

4th. When thus communicated, like the plague, four or five 
days usually intervene between exposure to the contagion and the 
appearance of the disease. For the evidence of the contagious- 
ness of the yellow fever in this country, let me refer you to the 
facts and observations published by the College of Physicians of 
Philadelphia, particularly to the evidence furnished by the late 
Dr. Kuhn, Dr. Wistar — Wistar's alone is sufficient and unan- 
swerable — Dr. Samuel Griffitts and others. They have borne 
testimony on this subject not to be controverted. See also the 



386 LECTURE XXXI. 

Medical and Philosophical Register, which has been chiefly de- 
voted to that object, and for which, in a great degree, that work 
was undertaken — and I trust it has not been unsuccessfully de- 
voted to this important subject, for it contains a body of facts 
attested by the most respectable evidence, and which I assert, if I 
know what truth is, is not to be resisted. Read the letters of 
Dr. Thomas, August, 1816, Sir Gilbert Blane, 1816, do. 1818, in 
which they express their astonishment at our physicians — 
"their inverted intellect." The yellow fever of Gibraltar in 
1804, recorded by Gilpin, in the 37th No. of the Medical 
and Surgical Journal of Edinburgh, for January, 1814 — yellow 
fever of Gibraltar, in 1813, Medical and Physical Journal, No. 
181— Burnett on the same subject, No. 184 — Pym's observations 
on the Bulam fever, as introduced in the West Indies, on the 
coast of America, Gibraltar, Cadiz and other parts of Spain — 
Medical and Surgical Journal, July, 1815, will furnish you with 
the most conclusive proofs of the contagiousness of this disease 
and of its introduction from the tropics into the other places 
mentioned. See also reports on its introduction from the 
Havanna into Barcelona, in 1821 — Walsh's Museum, No. VI. p. 
534. 

5th. That the yellow fever does not arise from putrid animal 
matter, the observations by Dr. Chisholm, which is in all your 
hands, in the appendix to Thomas, abundantly prove. That it is 
not the product of vegetable decomposition, the testimony of 
Dr. Stuart also satisfactorily demonstrates. Was it necessary to 
adduce additional testimony on this subject to show that this dis- 
ease has not originated from the tilth of your cities, I might re- 
fer you to the filthy condition of this city, in particular before 
the revolutionary war, and the offensive state of it during the war, 
when crowded with British troops, especially after the great 
fire of 1776, when the cellars of the numerous buildings then 
destroyed, were made the repositories of filth of every sort. At 
that time, too, we had nothing like a system of police regulations, 
yet we enjoyed an almost unexampled state of good health. But 
again, if we for a moment advert to the offensive state of our 
ships, our wharves and market places, our cellars, our privies, our 
tanneries, slaughter-houses, tallow chandleries, manufactories of 
glue, morocco, and starch, all of which, in the summer season, 
load the air with the most offensive vapours, and these, too, in 



YELLOW FEVER. 387 

the very heart of our city, without engendering this disease, 
we shall be compelled to look to some other source to which 
this disease must be traced — indeed, common sense rejects this 
doctrine as altogether puerile ; for were filth the parent of this 
disease, its annual return would be inevitable, both in the city 
and country. This result is unavoidable. Nay, every stable, 
farm-yard, or hog-pen, would engender it, if decomposed animal 
and vegetable matter is to be considered as the source of this 
form of fever. But remember a foul state of the air has its 
agency by spreading the disease in the manner already explained, 
when the poison has been introduced- But on this subject I 
need say no more; but shall proceed to notice the more prominent 
symptoms of this disease. 

Yellow fever, like the plague, frequently comes on by a violent 
invasion of the nervous system. In many cases, the persons ex- 
posed to the contagion are sensible of the effects of the poison, by 
its deleterious operation upon the brain, not by its offensive smell, 
but a peculiar operation upon the sensibilities of the system. The 
late Dr. Richard Bayley was conscious of receiving the poison to 
which he fell a victim, and declared the same at the time he was 
seized with his fatal illness ; yet that gentleman went to the qua- 
rantine ground an infidel on this subject : so says his successor, 
Dr. Joseph Bayley. Dr. Treet, another of our health officers, also 
died from this disease, contracted on board the Zephyr, the same 
vessel that introduced the yellow fever into this city in the year 
1795. On his way home, after visiting that vessel, he stopped at 
the house of the Rev. Dr. McKnight, and at Mr. Isaac Clason's, 
both of whom he informed, and from whom I received my infor- 
mation, that he believed he had taken the fever, which had been 
prevalent on board, and which had been very fatal at Port au 
Prince, from whence she had arrived ; he was immediately con- 
fined to his bed, and died in a few days with black vomit and all 
the other characteristic symptoms of this disease. His whole 
nervous system, at the time of his attack, was violently assailed; 
he felt great distress at the praecordia, some delirium, and at the 
house of these his friends, called for a cup of drink to counteract 
the distressing feelings he there experienced. Dr. Ledyard, an- 
other of our health officers, also entered upon his office an unbe- 
liever; but he was converted to the faith by a very short residence 
at Staten Island. Dr. Joseph Bayley, too, who had entertained 



388 LECTURE XXXI. 

some doubts upon this subject, and who, even at the time he re- 
ceived the honours of the College, expressed an equivocal belief 
of the contagious and specific character of the disease, in the 
Dissertation he published, has now the most unqualified belief of 
the opinions which I have expressed to you, that this, like the 
plague, is a disease sui generis. 

In its attack, like the plague, in some instances, it produces 
instant death ; in others, mania ; in most it comes on with a very 
acute distressing pain in the head, particularly across the fore- 
head, and oftentimes in the eyeballs themselves; in others it affects 
the brain by stupor ; the pain, too, usually is severe in the course 
of the back, and extends throughout the limbs, following the 
spinal marrow and larger nerves. In other cases, again, its force 
appears to be chiefly vented upon the praecordia, creating great 
anxiety and depression. 

This disease, in some instances, comes on with chill, and occa- 
sionally with rigors; but not so the greater number of cases; they 
are most generally without the chill attendant on intermittent and 
remittent fevers. 

The pulse is usually increased in frequency in the first stage of 
the disease. In some cases it is but little affected, in others it is 
soft throughout; in others it is slow and healthy to the last mo- 
ment of existence. 

The tongue is moist and clean too in some cases ; but in most 
slightly furred ; and in others covered with a yellowish sordes, in 
others a white fur. There is no thirst, or not usually trouble- 
some. The skin is flushed and hot, but sometimes so little affected 
that the patient is not usually considered to be very ill. 

The respiration is quickened and frequently very anxious, with 
much sighing and hysteria. The belly is costive. 

On the second and beginning of the third day, if not relieved 
by evacuations and by perspiration, with attention to the different 
excretions, a yellowness of the adnata of the eyes, of the neck, 
breast, and upper part of the arms, supervenes, and gradually ex- 
tends itself over the whole body. This symptom is probably 
occasioned by a change produced in the blood, and is not to be 
attributed to the absorption of bile, as many bave supposed. In- 
deed the biliary organs do not show any peculiar derangement in 
the commencement or at the early stage of the disease ; whereas 
the stomach is especially acted upon ; for it is, as expressed by 



YELLOW FEVER. 389 

Dr. Warren, the very seat and throne of the disease ; indeed, after 
death, it is found that in yellow fever there is rather a diminished 
secretion of bile, and very little found in the gall bladder. The 
disease too frequently occurs in the inflammatory, not the bilious, 
habit of body. It is otherwise in the bilious remittent; in that 
the biliary organs are at first affected, and show the effects of their 
derangement in every part of the system, in a yellow skin, yel- 
low eyes, yellow sordes upon the tongue, a bitter taste in the 
mouth, yellow turbid urine, &c. Nor is the yellowness which 
supervenes upon the third day of yellow fever, of the golden yel- 
low of bile, but of a different hue, partaking of the colour of the 
orange, mixed with the reddish hue of copper. The explanation 
given of it by Dr. Warren, of Barbadoes, that the serum derives 
its change from the decomposition of the blood, as is produced by 
the operation of poisons upon the system, or analagous to the 
changes produced in blood that is extravasated and has lost its 
vital principle, is, in my opinion, much more satisfactory; for a 
total decomposition, or death, very generally soon succeeds to 
this change of colour, and is attended with all the symptoms 
which, in fevers, announce dissolution, as hemorrhages, petechias, 
&c. About the same period that this yellowness displays itself 
upon the surface of the body, great irritation shows itself in the 
stomach ; a sense of heat and burning now takes place, attended 
with hiccup, and occasional gulping or disposition to return the 
drinks that may have been swallowed. At length they are rejected 
as fast as they are swallowed, and with some force ; and when 
drinks are not taken, the stomach still acts, spirting out portions 
of its contents analagous to the violent ejection of the contents of 
the stomach in the inflammation of that viscus, or in the inflam- 
mation of the oesophagus. 

Now succeeds a discharge of a dirty brown water, with a suffi- 
ciency of bloody turbid matter to give it that dark tinge, and at 
length a black matter is thrown off with the fluid ejected, and 
which sometimes falls to the bottom of the vessel; in other cases 
it floats on the surface of the fluid. This matter I have observed 
to exhibit itself in different forms. 1st. In flakes, like tinder, 
floating on the fluid discharged ; this I believe to be the effect o 
a sphacelus of the villous coat of the stomach, and which I have 
remarked is invariably fatal. 2d. It appears to be discharged 
in the form of blood and mucus which gradually subsides. But 
34 



390 LECTURE XXXI. 

the more common evacuation is that of the 3d, the coffee-ground 
discharge, and which immediately falls to the bottom of the ves- 
sel, precisely resembling the appearance of coffee-grounds, and 
which appears to be made up of broken or dissolved blood. After 
death, this has been traced to the coats of the stomach ; in other 
instances it has been followed into the gall bladder and biliary 
vessels, and is supposed to be discharged from the liver through 
the biliary vessels themselves, as if, to use the expression of Dr. 
Saunders, (see his Treatise on the Liver) it was blood hurried 
through the liver before it has time to undergo the changes 
necessary to be formed into bile ; in this manner 1 have seen it 
discharged in quarts ; in some instances, too, of diseased liver, I 
have seen such discharges, precisely like the black vomit of yellow 
fever. Another proof that the black vomit chiefly consists of 
blood is, that the strength rapidly and manifestly declines with 
every discharge from the stomach, the powers of life are sensibly 
wasted by each successive evacuation, as we ascertain by the loss 
of pulse, and the coldness of the extremities. 

Hemorrhages, too, now frequently take place from the bowels, 
gums, lips, tongue, nose, ears, and blistered surfaces. 

The proximate cause of this form of fever I consider to 
be an inordinate irritation of the system, the effect of the tro- 
pical heat acting upon the northern man, or of contagion, 
which has a definite or specific operation upon the body. When 
the disease proceeds from the first of these sources, and assumes 
more especially the character of the ardent fever, or causos, as it 
does in the insulated individual, and is not derived from conta- 
gion, our indication is, in that form of fever, to reduce the violent 
excitement of the system by the means of depletion already 
pointed out in cases of simple excitement ; but when it proceeds 
from the second source mentioned, from contagion, as is frequently 
the case during war, when a great number of soldiers and sailors 
are suddenly transported to the tropics, and the air is rendered 
impure by their crowded condition, and thence a septic state of 
system is induced, the indication is to moderate the action of this 
poison upon the system ; in other words, to place the body, like 
the ship exposed to a hurricane, in a condition to sustain its action 
and violence, with as little injury as possible to the vital organs, 
for you cannot annihilate the poison, but, like opium or arsenic, 
it will continue to operate until it wears itself out. Our object, 



TELLOW FEVER. 391 

then, is to prevent it from wearing out the system at the same 
time. For this purpose, then, open all the excretions, and keep 
them so until the enemy shall have disappeared ; not that you 
evacuate the morbid material, as some have supposed, though you 
do more or less of this, too, in all probability, but because in this 
open state of the excretory organs, and division of the excitement, 
the poison operating does less injury, because there is less fever, 
and fewer sources of irritation to augment the fever constituting 
the disease ; for the retention of faeces in the bowels, and of the 
perspirable matter from the suppression of the discharge by the 
skin, cannot fail to increase the violence and to add to the malig- 
nancy of the disease, inasmuch as these sources of excitement, of 
themselves, are frequently the causes of fever. But in the means 
we employ for this purpose of obviating febrile action, and in the 
evacuations we make use of, let us not conspire with the enemy 
in producing a destruction of the vital powers. Venesection, there- 
fore, when advisable, as is the case even in cases of fever from 
contagion, as we have seen, must be done early, cautiously, and 
judiciously, both as to quantity and repetition. We are not, how- 
ever, as Dr. Rush has recommended, to run the body under bare 
poles. To continue his figure, we should always keep enough sail 
to enable us to la}^-to during a gale, but not to be altogether at its 
mercy, or we assuredly shall be overwhelmed; for blood-letting 
has certainly been a fatal practice; death has very generally fol- 
lowed in the footsteps of the physician that has adopted it. As I 
have said before, upon another occasion, the indiscriminate use of 
the lancet in the yellow fever, as it has been pursued and recom- 
mended by some writers and practitioners, is adding the sword 
to the pestilence — it is putting arms in the hands of the enemy 
for our destruction. Most generally, the lancet may be dispensed 
with. In this country, as well as in Spain, particularly in Barce- 
lona, venesection was a fatal practice ; it was found otherwise by 
one of our navy surgeons, Dr. Cooke, in one of our armed ships. 
The best and most successful practice, in my opinion, consisted of 
mild cathartics, such as Glauber salts and castor oil, aided by lax- 
ative injections ; it is improper to wait for a slow cathartic. You, 
doubtless, recollect my statement of the success which attended 
the practice of Richardson Underhill, of this city, and of Thomas 
Penrose, John Vaughan, and William Clifton, of Philadelphia, in 
the epidemics of the two cities; and that these good Samaritans 



392 LECTURE XXXI. 

cured a much greater number of the sick by their castor oil, their 
catnip tea, their eupatorium, and their sage, than the graduated 
doctors of Europe or of this country, that directed what were de- 
nominated your Herculean remedies, the lancet, and their 10 and 
10, their jalap, and their calomel. 

Emetics, in this disease, are universally proscribed by all who 
have been particularly conversant with it, as a fatal practice, and in 
some instances ending in an unceasing vomiting. At this we are 
not surprised when we look at the cause of the disease, its violent 
action upon the nervous system, and the plentiful supply of ner- 
vous influence bestowed upon that organ, and the connexions it 
holds with the coeliac plexus and ganglions, and with the other parts 
of our frame. The practice found most beneficial after cathartic 
medicines have operated, is to relax the surface by sudorifics. 
These, when the bowels have been opened, are among the most 
beneficial means we can employ. This was the practice intro- 
duced by Dr. Warren, of Barbacloes; he learned it from a sailor. 
The same was pursued by Dr. John Bard, by Dr. Samuel Bard, 
and myself, in the endemics of our city. This consists, first, of 
washing the body with vinegar and water, applied cold or warm, 
according to existing circumstances ; cold, if the skin be hot and 
dry ; tepid washing and fomentations, if the body be moist but 
too much heated. Now the sp. minder, and laudanum, or the 
draught of Riverius may be advantageously administered, and re- 
peated every two hours : repeating also the cold washing as cir- 
cumstances may call for it; and giving frequently a cup of toast- 
water, or some diaphoretic drink. It is necessary to observe 
caution in the continuance of the sudorific mixtures when a free 
discharge by the skin is obtained, and not to continue them be- 
yond the first or second day, lest the stomach be too much debi- 
litated. Antimony is used by some, but this is hazardous in its 
operation. Mercury is bad for the same reason, in part. In warm 
climates, it is said to be a beneficial practice. This may be so 
where hepatic affections so extensively abound; but not so in our 
climate; with us it has been a fatal practice.* In like manner, it 
has been found injurious in Spain. 

Blisters to the region of the stomach should be early applied, 



* See my letter to Dr. Currie, of Philadelphia, in the Transactions of the Col- 
lege of Physicians of Philadelphia. 



TELLOW FEVER. 393 

to prevent the disturbance of that organ, and to counteract the in- 
flammation with which it is apt to be affected in that disease. If 
the yellow fever should again visit us, it will be one of my earli- 
est applications. It is useful, too, in allaying the irritations of 
that viscus, such as hiccup or black vomit. They are also ser- 
viceable applied to the limbs for the purpose of removing fever, 
and diverting the irritations of the system to a part. They are 
useful when applied behind the ears, and between the shoulders, 
to relieve the brain when congested or greatly disturbed. 

When black vomiting has been induced, have we any means of 
relieving that deadly symptom? As I have already observed, 
there are various anti-emetics. The most effectual of these is the 
mixture of lime-water and milk. My first application of it was 
in 1798. I was led to the use of it in that disease, by the bene- 
ficial effects I had derived from it in dyspepsia — it succeeded ad- 
mirably, aided by spirituous fomentations. There was a public re- 
commendation of it by Dr. Samuel Bard and Dr. Charlton: it was 
then communicated to Dr. Rush, who also, in his works, testified 
to its success. (See my letter to Dr. Currie.) Lime-water and 
porter may be used; or brandy and water, and spirituous foment- 
ations. Cayenne pepper also is good. It is Dr. Wright's pre- 
scription. Ice has also very happy effects. Spiced wine, with 
cinnamon, and blisters to the extremities may be advantageously 
resorted to. Let your patient's drink be cold water, toast-water, 
soda-water, mild teas of different kinds, as mint, catnip, snake- 
root, or boneset. Let his diet be altogether vegetable. 

With these observations I conclude our view of the first class 
of diseases, in which we have had a very varied and circuitous 
course to pursue, and one attended with much embarrassment and 
difficulty. In the next class, the plegmasiae, our path is more 
plainly marked. We may therefore, in allusion to the winding 
course in the one, and the clearly marked channel of the other, 
emphatically say — 

u Farewell to Thames, all hail to Tyber's stream," 

34* 



394 



LECTURE XXXIL 



PHLEGMASIA— INFLAMMATION. 



The term phlegmasia is derived from the verb $%£vfiatva, or 
<P^yw, uro — to burn. The inflammations or phlegmasia^ are thus 
defined by Dr. Cullen : " Febris synocha ; phlogosis vel dolor 
topicus, simul lsesa partis interna^ functione ; sanguis missus, et 
jam concretus, superficiem coriaceam albam ostendens." The 
bufly coat, I remark, is not essential, for inflammation exists with- 
out it ; and the bufly coat frequently exists without inflammation, 
as in the last stage of malignant fevers, and in pregnancy. In- 
flammation is a figurative term ; it is applied to this diseased con- 
dition of the human body, from a supposed accumulation of fire 
in the part affected, which was the opinion formerly entertained 
on this subject — a subject, too, upon which much speculation has 
been indulged, and various opinions and doctrines formed and 
propagated, as you will perceive by referring to the writings of 
Boerhaave, John Hunter, Burns, John Pearson, Cullen, Wilson, 
and Thompson. And to the same writers I refer you, both for the 
various doctrines which have been entertained upon this subject, 
and for the best records of facts or phenomena which this subject 
presents. Before we proceed to notice the various doctrines 
that have been promulgated upon this much disputed subject, or 
to institute any inquiry into their truth, let us adopt the same 
procedure that we have pursued in the preceding class of fevers, 
that is, before we involve ourselves in the speculations that have 
prevailed, let us look at the facts, the phenomena, which inflam- 
mation presents to our view. If those are sufficient to reason 
from, we shall, in that case, soon come at the clue by which those 
phenomena are to be unravelled, those general principles which 



PHLEGMASIA INFLAMMATION. 395 

arise from the facts when carefully assembled ; for as I have be- 
fore observed, general principles are nothing else but general 
associations of facts. Principles constitute the bond of union be- 
tween those facts. "Even the laws of nature," say Reid and 
Stewart, "are nothing else but the most general facts relating to 
the operations of nature which include a great many particular 
facts under them." How far then are the phenomena upon this 
subject sufficient to lead us to general results ? Let us for a mo- 
ment attend to the phenomena of inflammation. Suppose a 
splinter to be applied to any part of the body — the prick of a pin, 
a needle, lancet, or even the proboscis of a fly, or the sting of a 
musquito, or the application of a blister : what takes place ? 

1st. We are sensible of pain or irritation, some extra impres- 
sion of the parts, increased sensation, not increased sensibility, as 
Dorsey calls it ; this last frequently follows but does not precede. 
Avoid the abuse of terms, for remember, to a certain extent we 
may say, with Blair, M words are ideas." 

2d. We see the part reddened. We see red blood circulating 
where it did not circulate before, as in the eye and other mem- 
branous parts ; and where red blood circulated before, but the 
globules were not perceptible, now with the aid of glasses we see 
larger globules actually flowing in the vessels, and the vessels 
themselves are enlarged. 

3d. We shortly after perceive tumour or swelling. 

4th. The heat of the part is perceptibly increased and accumu- 
lated, attended with a sense of burning to the patient, and evident 
to the by-stander. 

5th. These symptoms are followed by a throbbing or pulsation; 
vessels now pulsate that never did before, that is, as it regards 
our feelings or our consciousness. This is especially observed in 
the most sensible parts of the body, as in the fingers, where the 
nerves are numerous. The cause of the irritation being with- 
drawn, removed, or worn out, or the impression not being very 
considerable, those symptoms soon subside ; but if the cause be 
continued or the effects be severe, and 

6th. The irritation be continued, it extends beyond the part 
to the vicinity — to the whole limb, following the course of the 
nerves in lines which are observable. To the patient the sensa- 
tion communicated, is that of hot wires passing through the parts 
affected; and 



396 LECTURE XXXII. 

7th. The whole system becomes involved in the irritation pro- 
duced, and that in proportion to the sensibility of the system, 
and the sensibility of the parts. Fever ensues with all the cha- 
racters of synocha, viz : the hard pulse, white tongue, diminished 
excretions, or, 

Sth. A new increase of excitement takes place in the part, for 
a new vis a tergo is now acting upon the inflamed vessels — they 
become highly injected, for the great syringe is now operating — 
I mean the heart and aorta, with the other large vessels, are all 
now highly excited ; a great determination takes place to the seat 
of irritation ; a disproportionate quantity of blood is carried to 
the part, and accumulation or congestion is the consequence — 
pain, throbbing, tumour, heat, and redness, are all increased. 
Such are the general symptoms of inflammation in its first stage, 
as occurring in most parts of the system. They have been long 
since noticed, even as early as the time of Celsus. " Notse vero 
inflammationis," says that author, " sunt quatuor; rubor et tumor 
cum calore et dolore." These several forms or grades of inflam- 
mation proceeding, terminate in different ways. 

1st. By resolution, in which all those symptoms disappear, 
either suddenly or gradually. This event takes place either 
when the degree of irritation is very inconsiderable, or the re- 
mote cause is suddenly withdrawn. 

2d. It may terminate by an effusion from the inflamed vessels. 
This effusion may consist (1) of blood. Of this we have exam- 
ples in ophthalmia, catarrh, dysentery, inflammation of the lungs, 
viz: peripneumony — two cases of this latter disease ending in 
such effusion, are related by Carmichael Smyth, as communicated 
to him by Dr. Cullen — in one, blood was extravasated, in the 
other, a bloody serum was poured out. Analagous cases are also 
related as taking place after typhus fever. A second form of 
effusion is that of serum; it is poured into the cavities of the 
body, as in the head, the chest, or belly, producing dropsy in 
those cavities ; and in some instances almost immediate death. 
The late Dr. Charlton, of this city, died of such effusion in the 
chest, under an attack of pneumonic inflammation. (3d.) Pus is 
also effused as the result of inflammation, called suppuration. 
(4th.) Another discharge is that of a material bearing some re- 
semblance to pus, but which mostly is considered to be coagulable 
lymph. In such cases adhesions take place, for vessels readily 



PHLEGMASIA INFLAMMATION. 397 

strike through such media. This effusion shows itself in the 
trachea, bronchia?, lungs, and contents of the brain and belly. 
Another deposit which I have seen as the effect of inflammatory 
action, is earthy or bony matter, as from the kidneys. 

3d. Inflammation when seated in the nicely organized struct- 
ure of a gland, may end in a permanent obstruction of the part 
called a scirrhus of such gland. This obstruction may again end 
in an open ulcer, or as it is absurdly called, a cancer of the gland. 
Goitre is thus induced. This disease is usually ascribed to snow- 
water. I believe it is owing to the alternations of atmosphere to 
which the inhabitants of the Alps are exposed. At the same time 
that other causes may possibly have an agency in the enlargement 
of those glands of the neck. I have accordingly placed goitre 
under the head of scirrhus in my nosology. 

4th. Inflammation terminates in sphacelus or gangrene — in the 
bone, this death of the part is denominated necrosis. 

But inflammation exhibits a different train of phenomena, de- 
pending on peculiar circumstances. What are these circum- 
stances ? Inflammation varies in its operation, phenomena, and 
duration, depending on the structure of the part, -the seat of the 
inflammation.* 

1st. Inflammation exhibits peculiar phenomena when seated in 
the cellular membranes, and the fleshy, muscular fibre. 

2d. It shows another train of appearances, and that throughout 

* Mr. Hunter divides the body in two parts. 

1st. The circumscribed cavities, organs, and cellular membrane connecting 
them. 

2d. The outlets of the body called mucous membranes, as the ducts of the 
glands, alimentary canal, and similar organs. These two parts he makes the sub- 
jects of different inflammations. His inflammations are, first, adhesive ; second, 
suppurative ; third, ulcerative. The first, that is, adhesive, takes place in the first 
class of parts, the circumscribed cavities and organs and cellular membrane, that 
is, where deeply seated. Suppurative in those superficially seated. Ulcerative in 
the second class, the outlets of the body. There are objections to this view. He 
does not distinguish between the texture of the organ and its membranes inclosing it. 
Even deeply seated suppuration will take place. The adhesive, too, will take 
place in those membranes near the surface, though he considers them more liable 
to the suppurative. And again he makes a very absurd distinction between sup- 
purative and ulcerative, for the latter always implies suppuration. Nor are the 
mucous membranes so likely to ulcerate as other parts — nor do his distinctions 
provide for all the various forms and consequences of inflammation. I have 
therefore, adopted a different arrangement, and I trust, one no less subservient to 
practice, 



398 LECTURE XXXII. 

its whole progress when this inflammation is seated in the mucous 
membranes, or in the excretory vessels composing the various 
excreting surfaces of the body. 

3d. It is again peculiar in its phenomena when seated in those 
dense membranes which are internal, having no excretion or exit 
from the system, called serous membranes, by Bichat ; and 

4th. Inflammation differs in its nature and consequences when 
seated in those organs which are supplied with a great number of 
nerves, which of course, possess great sensibility, and are thence 
intimately connected with life and health. I beg your attention 
while I endeavour to illustrate these characters of inflammation. 

Inflammation, I observe, has its peculiar characteristics when 
seated in the cellular membrane, or cellular tissue, as is the fash- 
ionable language. Observe, I include under this head, not only 
the cellular and adipose membrane, which is seated in the integ- 
uments below the skin; but also as it exists in the parenchyma of 
the various viscera contained in the different cavities of the body; 
even, perhaps, as seated in the substance of the brain. For as it 
regards practice, this distinction is highly important, as it leads us 
to look for inflammation in the brain when the usual phenomenon 
of inflammation might not otherwise point it out. Accordingly 
we have seen in the history of fevers that inflammations termi- 
nating in abscesses have not been discovered until after death. 
(See Pringie.) Not so in membranous inflammation of the brain. 
I say, I include the parenchyma of the lungs. I include the 
cellular membrane, as seated in the glands of the system, (and in 
those organs resembling glands in their structure, whether with or 
without excretory ducts, as the uterus and spleen,) as opposed to 
membranous inflammations. Observe, the glands and some of 
the viscera are included as having a loose, spongy texture, being 
chiefly made up of cellular membrane, uniting the blood-vessels 
and nerves through all their infinitely numerous ramifications. 
Under this head I include the liver, spleen, pancreas, kidneys, 
uterus, ovaria, testes; the tonsils, the thyroid gland, the parotid, 
the cervical, the axillary glands, the mammae, the cellular mem- 
brane, &c, distributed in the muscles; the muscular fibre itself, 
which is considered by many physiologists as a condensed cellular 
membrane; the internal texture of the bones, the cancelli of the 
bones, in which, like the inflammation of the periosteum, inflam- 
mation frequently ends in necrosis. 



; 



PHLEGMASIA. — INFLAMMATION". 399 

2d. Under the head of external secreting membranes, and ex- 
creting surfaces, I include the skin, the palpebral, the tunica adnata, 
the meatus auditorius externus, the mucous membrane lining 
the nares, fauces, larynx, trachea, bronchia?, surface of the lungs, 
the pharynx, oesophagus, stomach, gall bladder, and biliary 
vessels, the intestines, surface of the whole intestinal canal, 
also of the urinary organs, ureters, bladder, urethra, corona 
glandis, uterus, vagina, labia; even the excretory surface at 
the ends of the fingers, where the skin covers the nail, the seat 
of paronychia, or whitlow, vulgarly called runrounds. All these 
several parts have an exit from the system, of the secretions which 
take place upon their several surfaces. Under the head of the 
internal membranes, where the secretions are of a serous nature, 
different from those enumerated, and have no exit from the body, 
no discharge of the matter secreted, I include a great number, be- 
ginning with the membranes constituting the coverings of the 
brain; those composing the internal coats of the eye, those of the 
thoracic viscera, whether lining the chest or its productions cover- 
ing the different viscera; the pleura lining the ribs, and covering 
the lungs; the pericardium, the covering immediately investing 
the heart, the mediastinum; the abdominal membranes, the peri- 
toneum lining the belly, or involving the different viscera. The 
membranes found in the pelvis, as the peritoneum covering the 
bladder, the uterus and intestines; the membranes inclosing the 
testes, the fasciae covering and binding the muscles; those consti- 
tuting the bursge mucosae, or sheaths of the tendons; those con- 
stituting the capsular ligaments of the joints and pelvis, as the 
sacro iliac and sacro sciatic ligaments; the periosteum lining the 
pelvis covering of bones of the extremities, and the pericranium. 
I have also said that inflammation is attended with peculiar 
phenomena when seated in organs plentifully supplied with nerves, 
as the skin, mouth, fauces, stomach, intestines, bladder, and ute- 
rus. I shall now proceed to enumerate the particular phenomena 
which attend inflammation when seated in these four classes of 
organs. When seated in the cellular membrane, the adipose mem- 
brane, or in the fleshy muscular fibre, inflammation is attended 
with more tumor; the parts being of a relatively loose texture, 
they are more distensile and elastic; and they exhibit more 
pulsation from the same cause. This species or variety of in- 
flammation was known to the Greeks by the name of phleg- 



400 LECTURE XXXII. 

mon, (from q>%eyn 9 uro.) Galen has well denned it in his work 
De Tumoribus Prseter Naturam, Lib. i. cap. 2. " Hoc phlegmones 
nomen Grsecis dici consuevit, de carnosis partibus; majorem in 
molem, cum tensione, renixu, dolore pulsatorio, calore et rubore, 
extuberentibus." He should have added to this enumeration the 
usual termination of inflammation thus seated ; viz. by suppura- 
tion or abscess. This inflammation, too, is generally of longer 
duration; the parts being less sensible, its termination will not be 
so rapid. It is also on the same account less painful than some 
other inflammations to be noticed. The external parietes, at the 
boundary of the tumor, being inflamed, form an union of many 
of its fibres by cohesive inflammation, making a kind of wall; 
but in this the inflammation is less violent than that in the centre 
of the tumor. In the centre, where the inflammation is most 
active, effusion at length takes place of purulent matter; a viscid 
secretion of considerable consistence, corresponding with the en- 
larged dimensions of the vessels, and this is sometimes mixed 
with blood. This matter, acting as a foreign body, excites the 
absorbents. The skin adjoining the matter is rendered thin; it 
points and finds an exit in that direction where there is least re- 
sistance; not that it finds the surface by an instinctive operation, 
as Dr. Good supposes. Instinct does not always direct it to the 
surface: instinct is generally unerring. The other parts of the 
cavity show similar changes. If in the lungs or liver, consider- 
able removals of their substance takes place, leaving large cavi- 
ties. I have seen a case of this kind in Bridewell, another in the 
New York Hospital, and a third in Cherry street. The two first 
recovered, the third died. I examined him after death. The liver, 
diaphragm, and lungs were all consolidated; there was a large 
aperture, sufficient to permit my arm to pass through. In this 
last case, too, the inflammation was so insidious that a very emi- 
nent and experienced physician did not detect the real state and 
nature of the disease, but treated it as a case of hypochondriasis 
by gum pills, and the decoction of the woods. Diseases of the 
liver were then not as well understood as at this day. In another 
instance I have seen a large portion of the rectus muscle carried 
away by absorption, the effect of the stimulus of an encysted tu- 
mor, acting upon it as a foreign body. This tumor was removed, 
and disclosed the ravages it had created upon the neighbouring 
rectus muscle. I have seen another case of the gastrocnemius 



. 



PHLEGMASIA. INFLAMMATION. 401 

nearly excavated by an abscess. Upon examining the interior of 
an abscess this is not all; the cellular membrane which first made 
the seat of the tumour, is also in a great degree removed, and pus 
found in its place, mixed with some remaining fibres, probably of 
vessels. This little mass of vessels which remain, is vulgarly 
called the core of such abscess; i. e. a mass of the vessels which 
were perhaps the first seat of the inflammation. This core is kept 
in its place by a few of the fibres or remaining vessels still ad- 
hering to particles of the abscess. Hence time is required to 
remove this core from its connexions. It is important, too, to 
remember that inflammation, when thus located in cellular sub- 
stances, is less painful, and of course more insidious, as in the 
liver, lungs, and brain. The pulse, too, manifests it less than 
when seated in the mucous, the dense or serous membranes; and 
still less than in the more sensible organs that have been enume- 
rated; as the skin, the stomach, uterus, &c, the whole symptoms 
of general irritation are less. Indeed we may observe, that phleg- 
monoid inflammation scarcely ever appears but in the cellular 
membrane, or in those organs abounding in it, as the brain, lungs, 
liver, kidneys, muscles, as the psose, producing the psoas abscess. 
Their loose texture, in a particular manner, admits of this extra- 
ordinary distension — this tumor, the pulsation, and secretion or 
effusion of a fluid of the consistency of pus, having globules 
nearly resembling in their size the globules of blood. 

I believe such purulent effusion rarely appears otherwise. I say 
rarely, for I have seen, in some instances, a purulent secretion 
from the surface of the intestines, floating over the surface after 
enteritis. We also sometimes find an analogous enlargement of the 
vessels upon the surface of the lungs, and a purulent fluid dis- 
charged from the surface, and proving fatal, exhibiting all the 
symptoms of phthisis; and yet upon examining the lungs after 
death, no abscess, no vomicae, no phlegmonous collections are to 
be found, not even the least appearance of ulcer. The next form of 
inflammation is that which is seated in the secreting membranes, 
especially those pouring out mucus, and which have an outlet 
from the system. Those membranes are more soft or spongy, less 
dense than the internal membranes, and they have a villous surface 
supplied with numerous follicles pouring out fluids ; these, being 
of a mucous nature, defend those surfaces from any acrid materials 
that may flow over them. We have examples of these secreting 
35 



402 LECTURE XXXII. 

membranes in the lining of the nares, fauces, bladder, urethra, and 
uterus. The effect of inflammation, when seated in those membranes, 
is an increased thickness of them ; the villous surface becomes red 
and spongy, with great heat and soreness ; it is attended with but 
little acute pain, except such as arises from the acrid fluids pouring 
over their inflamed surface. The fluid itself, which such membrane 
secretes, becomes changed ; instead of being ropy and adhesive, it 
becomes thin and acrid, losing its tenacity, and excoriating the 
neighbouring parts ; now at length it becomes somewhat purulent, 
and then soon returns to its original consistency and qualities. As 
there is not much acute pain, there is, therefore, comparatively little 
fever, except when the inflammation becomes deeper seated, reach- 
ing other organs beneath the part primarily affected. Fever is not 
generally produced to a great extent by the inflammation of mu- 
cous membranes, (for the inflammation to a degree at least appears 
to be moderated or diminished by the discharge,) though fever 
produces ^inflammation in them. When terminating favourably, 
the discharge, from being first thin and acrid, becomes purulent; 
afterwards it recovers the properties of a bland mucus, with all its 
tenacity and transparency. But when the inflammation is greater, 
it ulcerates the membrane itself, and sometimes even extends to 
the parts deeper seated, producing abscess or phlegmonoid inflam- 
mation ; even sometimes ending in gangrene, as in the bladder, 
intestines, womb, &c, but this is not the usual termination of 
inflammation seated in the mucous membranes. This inflammation 
of mucous surfaces is also oftentimes chronic, while the preceding, 
and those which are to follow, are acute ; with some exceptions, 
as when dense membranes, or even the cellular, are the seat of 
scrofula or of lues, even the dense membranes, as well as the 
cellular membrane of glands, then become affected with chronic 
inflammation, depending then, however, more upon the nature of 
the cause than the structure of the part, the seat of . the inflam- 
mation. In the inflammation of mucous surfaces, sponginess, red- 
ness, and great sensibility remain in the parts affected ; the fluid 
secreted remaining sharp and corrosive. 

The third sort of inflammation is that which is seated in dense 
membranes, which are internal, having no external outlet for the 
matter they secrete, and the matter secreted is thin and serous ; 
from their dense structure, Haller thought them insensible, and 
incapable of inflammation; he even thought a pleurisy to be seat- 



PHLEGMASIA INFLAMMATION. 403 

ed in the intercostal muscles, and not in the pleura. Haller was 
a much better anatomist and physiologist and poet, than physician. 
It is now ascertained that those membranes, as of the brain, lungs, 
peritoneum, &c, when inflamed, are exquisitely alive to impres- 
sion ; the sufferings of a periostitis are inexpressible. In the 
membranes of the joints, the same sensibility is manifested when 
inflamed, especially upon the admission of air to the cavity of the 
joint; this being a stimulus to which they are unaccustomed. I 
have seen a very violent degree of inflammation induced in the 
cavity of the knee joint, by discharging a large collection of water 
from it. The operation was performed by Mr. Bennett and 
John Bell. Although it was performed in such a manner as to 
make the least possible wound, and with a valvular opening allow- 
ing the water to flow off, and as far as possible to exclude the air; 
a most violent inflammation ensued, and ultimately proved fatal. 
Mr. Bell then declared that this event had so frequently taken 
place, that he would open no more joints. The symptoms of in- 
flammation in dense membranes, are violent pain and irritation. 
Why more so in these than other membranes ? Because of the firm 
unyielding texture, resisting the distention that takes place in 
other parts, from the quantity of fluids loading the inflamed ves- 
sels. Great fever is of course to be expected as the consequence 
of such irritation ; the membrane itself is thickened and becomes 
opaque ; an excretion of a matter like lymph is poured out upon 
its surface, sometimes a turbid serum, and in other instances, bear- 
ing a resemblance to very thin fluid pus. An adhesion to the 
adjoining inflamed parts also frequently takes place ; in some 
cases I have known the parts to slough, as in the case of an in- 
flamed testicle, in which case the coats of the testis were peeled 
off in succession, like the coats of an onion. In a pleurisy, the 
patient suffers a severe pungent pain, with a short and painful 
cough, the pleura becomes thickened, and often a gelatinous effu- 
sion and adhesions are the result. In some few cases, such pleu- 
ritic inflammation ends in serous effusion or hydrothorax, while, 
in still fewer, I have known it to end in sphacelus. So, in like 
manner, peritoneal inflammation is attended with intense pain, fol- 
lowed by gelatinous exudation, adhesion, serous effusion, and 
sphacelus. In inflammation of dense or serous membranes, as 
Bichat calls them, the pulse is quick, hard, and small; the fever 
too attending it, is greater, as we see in inflammation of the mem- 



404 LECIXTRE XXXII. 

\ 

branes of the brain, periostium, &c. Inflammation is also peculiar 
in parts highly organized by nerves, and thence possessing great 
sensibility, as in inflammation of the skin, the mouth, fauces, sto- 
mach, intestines, bladder, vagina, uterus. Inflammation in either 
of those organs is painful, from the irritation applied, in conse- 
quence of the great sensibility of the parts. Excitement is then 
reproduced throughout the whole system ; it is rapid of course in 
its termination, for the vital powers of those parts are soon worn 
out, and sphacelus, the common consequence, is produced. We 
see examples of this sort in the skin ; as sphacelus from blisters, 
especially in children, or in fevers where, from their long applica- 
tion, the vital principle is already impaired, also, sphacelus from 
erysipelas ; hence, too, the fatality of burns, especially in the sen- 
sitive systems of children. In the fauces, in like manner, inflam- 
mation rapidly ends in gangrene. The inflammation of the intes- 
tines in dysentery, as we have seen, is in some instances rapidly 
fatal in this manner, by terminating in sphacelus ; in the inflam- 
mation, too, of puerperal fever, the same result is not uncommon. 
Beware how you deceive yourselves by cold extremities, a pale 
face, or a small pulse ; do not by them be deterred in the begin- 
ning from an active antiphlogistic treatment; on the contrary, 
remember the cause and seat of these phenomena, and let them 
teach you that they are the very reasons for your greater activity 
in the use of those means that are indicated ; and remember, too, 
that the first six hours are your time of action,' and of securing 
your patient's safety. It is important, therefore, to know these 
facts, not only as it regards their symptoms, but your cure. The 
natural termination of those various inflammations leads to impor- 
tant conclusions, in this respect: they teach us, if we cannot rea- 
dily obtain resolution by active and early measures, to guard 
against adhesion, and especially gangrene and sphacelus, for we 
have seen, 

1. That when inflammation is seated in the cellular mem- 
branes, the tendency to suppuration is scarcely to be counteracted. 

2. That when seated in mucous membranes, the inflammation 
is less severe and more manageable. 

3. That in dense membranes adhesion is to be expected. 

4. That, seated in parts highly organized, there is no time to 
be lost, or it will end in gangrene or in sphacelus, as in the treat- 
ment of the inflamed part locked up in the stricture of hernia. 



405 



LECTURE XXXIII. 



PHLEGMASIA.— INFLAMMATION. 



Inflammation not only varies in its nature and consequences, 
according to the structure and sensibility of the parts in which it 
may be seated, but it also varies in its character, depending on its 
remote or exciting causes. Ophthalmia, for instance, may proceed 
from cold; it may proceed from scrofula, or it may be the effect 
of syphilis. According as it proceeds from any of these causes 
it exhibits a different train of symptoms; is of long or short du- 
ration; and requires a different mode of treatment. In that from 
cold, it is attended with fever; in that from scrofula or syphilis, 
it is most generally without fever, or it is comparatively mild. 
That from cold is of short duration; while that from the other 
two causes is tedious, and does not yield to the same treatment. 
In that from cold, the antiphlogistic treatment is called for, and 
alone affords relief; while in the other, the lancet and other means 
of depletion are of little avail, and the disease is only to be re- 
moved by the antidotes to the peculiar vice with which the sys- 
tem may be affected. For the most part, the physician, by atten- 
tion, will readily know the one from the other, by the more 
active form of the one, and the less violent symptoms of the other. 

But unless we advert to the cause we shall be unsuccessful in 
our treatment of this disease. Inflammation of the throat may 
in like manner arise from cold. 2. Contagion, as in cynanche ma- 
lig. 3. Syphilis. 4. Or even from mercury. The two first and 
the last, i. e. from cold, contagion, and mercury, are attended 
with fever. That form of syphilis is most usually without fever : 
but the latter calls for peculiar treatment. Mercury alone is the 
remedy. But if mercury is the source, other means must be 
directed. 

35* 



406 LECTURE XXXIII. 

Again, glandular affections, as obstructions of the lymphatic 
glands of the neck, may proceed from, 1. Cold; or from, 2. Teeth- 
ing; 3. From scrofula; 4. Or from syphilis; 5. From porrigo — scald 
head. The two first are attended with more or less of fever; the 
other none, except what the humours themselves may create. In- 
flammation of the joints may also arise in like manner from cold r 
from gout, from scrofula, or from syphilis, Mr. Pott's skill be- 
came celebrated for detecting the last mentioned cause in two 
eases which fell under his care, of disease of the joints. We see 
the same illustrated in an inflammation of the skin, that it exhibits 
different phenomena, is more or less dangerous, and has different 
terminations, according to the causes which produce it ; and con- 
sequently that it demands, according to the nature of the causes 
producing it, a different mode of treatment. We see erysipelas 
from cold, also from heat, from intemperance; we see it from 
gout; i. e. from an inflammatory habit of body, or from plethora; 
we see it in the form of of an erythema, the effect of mercury ; 
and we see it the effect of a general septic state of the fluids. 
To prescribe successfully, these causes must severally be kept in 
view in our prescriptions. Celsus has very justly said, " Eum 
recte curaturum quern prima origo causae non fefellerit." That 
he will readily cure diseases who is not deceived with regard to 
the causes of them. Such are the phenomena of inflammation; 
and by these circumstances they are influenced; viz. by the struc- 
ture of the part in which it occurs, and the nature of the cause 
producing it. 

Let us next briefly inquire, what are the several remote causes 
of inflammation. They divide themselves into the predisposing 
and exciting causes. The predisposing causes are, 

1. Certain temperaments of body are more susceptible of in- 
flammatory diseases than others; as the sanguine and nervous 
temperament. 

2d. Debility, by producing great sensibility, predisposes to in- 
flammatory diseases. Hence we see the same person more liable 
to a second attack, and of the same disease ; i. e. this debility 
shows itself in the part as well as the whole system. 

3d. Climate has its influence, as a predisposing cause. A climate 
in which many vicissitudes of weather occur, or a very hot lati- 
tude produces inflammatory diseases, as we see illustrated in our 
own climate, to which the character given of that of Pennsylva- 



PHLEGMASIA. INFLAMMATION. 407 

nia may with great truth be applied. Dr. Rush observes of it, 
that it is uniformly variable. 

4th. Certain seasons of the year, for the same reason, as spring 
and autumn, predispose to diseases of an inflammatory character. 

5th. Manner of life: a full habit of body, our beefeaters, and 
five-bottle men, are the candidates for gout, as well as other dis- 
eases of plethora and inflammation. They not only act by the 
fulness they create, but by the indirect debility which they 
induce. 

6th. Females are more liable to inflammatory diseases than 
males, both from their natural delicacy and sensibility of frame, 
as well as that sensibility which is the effect of confinement and 
sedentary habit of living. Cynanche tonsillaris, pneumonia, end- 
ing in phthisis and hemorrhage from the lungs, come from the 
same cause. Rheumatisms are of much more frequent occurrence 
in the female sex than in ours. 

7th. Time of life has its agency in this respect. Infancy and 
childhood, in an especial manner, predispose the body to certain 
inflammatory diseases. It is the preternatural sensibility of in- 
fancy that renders them so liable to anginas, to croup in particu- 
lar, and to pneumonia; especially those inflammatory diseases 
which are seated in the mucous membranes, are the predominant 
diseases of that period of life. 

8th. A plethoric habit of body predisposes to the same class of 
diseases ; for the secretions in such being more abundant, they 
are also, by the application of cold, or other exciting causes, more 
easily checked; and in such habits of body the inflammation in- 
duced is more violent. 

The exciting causes may be said to embrace every means of 
quickening the circulating system. 

1st. Mechanical injury, as (1) wounds inflicted by instruments; 
the wounds from a ball; from splinters; even friction of the 
thighs by riding or walking, proves an exciting cause of inflam- 
mation. (2) The irritation arising from calculi, as in the gall-blad- 
der ; biliary ducts; kidneys; ureters, or urinary bladder; or de- 
posited in other parts, as the lungs. 

2d. Cold partially or suddenly applied. 

3d. Heat, either from the direct rays of the sun, or by fire. 

4th. The alternate operation of heat or cold, as in the changes 
of atmosphere. 



408 LECTURE XXXIII. 

5th. Animal stimulants, as the stings of various insects. 

6th. Vegetable stimulants, as turpentine, the effluvia of the 
cashew nut, anacardium occidentale; the foetid liquor exuding 
from the urtica urens. 

7th. Chemical, or metallic stimulants, as the oxydes of arsenic, 
mercury; the mineral acids, as the nitric, muriatic, and sulphuric 
acids, caustic alkali, quicklime. 

8th. The peculiar acrimony of diseases, as syphilis, scrofula, 
and especially, 

9th. The diseases of contagion, of which there is a great va- 
riety, as measles, catarrh, small-pox, scarlatina, &c. 

10th. The irritation of fevers, and especially synocha; and, 

11th. Obstructions of vessels; that is, partial determinations 
taking place, as in fevers, to particular organs, as to the brain, 
lungs, &c, especially when they have before been the seat of irri- 
tation. These local inflammations supervene as the attendants on 
fever. Thus, too, we see glandular swellings in the advanced 
state of fevers, and other diseases, as from syphilis, scrofula, 
typhus fever, plague, or yellow fever. But obstructions are also, 
in many cases, the causes, as well as the consequences of inflam- 
mation as in the mammse, when obstructed sometimes. Such ob- 
struction creates inflammation, and that, too, whether it be a re- 
cent obstruction from milk, or it may have been an old scirrhus. 
In either case it may be the cause of active inflammation. In this 
way the former may end in abscess; the latter in cancer; i. e. 
ulceration, the effect of inflammation in the obstructed part. 

Again, we see collections of blood in the hemorrhoidal vessels 
not only painful in themselves, but such is the irritation excited 
that a phlegmon, and that terminating in fistula in ano, are the con- 
sequences. In like manner, accumulation of blood in the uterine 
vessels, the effect of suppression of the menses by cold, or a sud- 
den check of the lochia, not only creates great distress and sore- 
ness, but puerperal fever; i. e. uterine and peritoneal inflamma- 
tion. In some cases, scirrhus and cancer uteri are the consequences 
of the natural cessation of the menses; and such inflammation, 
like that affecting the liver and lungs, is frequently insidious in 
its approach; or, as I have said before, speaking of the inflamma- 
tion in mucous membranes, it is perhaps, partially relieved by a 
degree of fluor albus, that is frequently the attendant upon such 
uterine obstructions. An analogous suppression of accustomed 
excretions from the surface of the body, from the intestines, from 



PHLEGMASIA. INFLAMMATION. 409 

the biliary canal, or from the urinary organs, by creating a new 
stimulus to the parts, and indeed to the whole system, also produces 
inflammation and its consequences. Even sphacelus is in this 
way not unfrequently the effect of the suppression of urine. 

Thus, too, we see the check given to the excretions from the 
throat, trachea, lungs, nose, lachrymal glands, produces inflam- 
mation of those organs. Even the glandulse meibomii obstructed 
produces psoropthalmy, or perhaps the hordeolem, or common 
stye. Indeed, all such obstructions become the immediate causes 
of irritation, by creating a fulness of the vessels of the parts, and 
thence extending that irritation more or less to the whole sys- 
tem, depending upon the extent of the connexions which such 
part may hold with the general system. 

Having taken this view of the phenomena and remote causes 
of inflammation, we are prepared to inquire into, and to appre- 
ciate the different opinions relative to the nature of that diseased 
condition, and I trust, too, to perceive their insufficiency, as 
that of Dr. Hoffman, after him adopted by Dr. Cullen. They 
supposed the proximate cause to consist not only in increased 
action of the blood vessels, but also a spasmodic stricture of their 
extremities. This spasm, as in fevers, may be the consequence, but 
not the cause — it may be an aggravating circumstance, but it is 
not essential to inflammation. The distended vessels may be 
spasmodically affected, or they may not be. Therefore, such 
spasm is not essential to the inflammation any more than it is 
essential to fever; or that spasmodic action in the trachea is essen- 
tial to the inflammation of the membrane lining that tube, yet it 
is a common consequence in all. But let us not confound causes 
and effects ; let us not identify causes with consequences. Ac- 
cording to Dr. Boerhaave's view of this subject, inflammation 
consists in what he denominates an error loci ; that is, that the 
small vessels containing blood, which vessels did not before con- 
tain it, are the seat of, and constitute inflammation. This doc- 
trine is certainly a near approach to the truth, as corresponding 
with the phenomena we have seen ; but alone it does not consti- 
tute the whole truth. Effusion of blood frequently takes place in 
the loose texture of the eye-lid, nay, in the very adnata of the 
eye ; yet no inflammation attends or follows such effusion. 

There is then, something more wanting, namely, an impacted 
state, a forcible entry of such blood vessels, so as to create 



410 LECTURE XXXIII. 

pain and irritation, is necessary ; and frequently there is no er- 
ror loci in inflammation, except in as far as a disproportionate 
quantity of blood may exist in the very vessels in which it cir- 
culated before. Vacca, preceded in this theory in 1766. Mr. 
Latta's opinion is also somewhat original on this subject. He 
believes there is a deficiency of action in the part, and a para- 
lysis of the vessels instead of spasm. These, too, are doubtless 
the effects, but not the causes of inflammation. The capillaries 
being overloaded, more or less of obstruction necessarily follows, 
and hence effusion is the consequence. Diminished action, how- 
ever, although it may exist, is not the cause but the effect of such 
inflammation ; for it appears in the greatest degree when the in- 
flammation is at an end, as illustrated in the experiments of Wil- 
son : like Dr. Cullen's debility, it comes too late to be a cause ; it 
is only in time to be the consequence. Again, this paralytic state 
which Mr. Latta supposes to exist, is certainly very inconsistent 
with the local irritations attendant upon inflammation. It is alto- 
gether inconsistent with the pain, the heat, the redness, and the 
tumour attending the part. Paralysis of the part, like paralysis 
of the whole system, may be the consequence of plethora and ob- 
struction, and probably is so. In like manner, too, the debility 
of the capillaries of the part, is not essential, as stated by Wilson. 
He, too, has the cart before the horse. The preternatural disten- 
tion doubtless exists, but the other does not necessarily follow, 
from the facts he has adduced, any further than as a consequence 
of the distention ; but this debility has nothing to do with it as a 
cause of the inflammation, any more than debility is the cause of 
fever. It may be a predisposing cause in both cases ; but in this 
respect it is not essential to fever, nor to constitute inflammation. 
It necessarily, however, follows great distention and excessive 
action, but does not necessarily beget either or precede either. 
Another opinion has been lately advanced from that hot bed of 
speculation, Edinburgh. I refer to the view taken of this subject 
by Dr. Thompson, the Professor of Military Surgery, as con- 
tained in his volume of Lectures on Inflammation. That is, that 
in some cases the vessels acted upon, are readily distended by 
the exciting cause, constituting the passive inflammation ; in others 
they are not previously debilitated, and therefore resist the im- 
pulse a longer time, constituting the active form of inflammation. 
These are certainly facts not to be questioned — they, however, 






PHLEGMASIA INFLAMMATION. 411 

merely show, as I have said before, that debility predisposes the 
part to be more easily acted upon, but that it is not essential to 
constitute the proximate cause of inflammation. 

Let us next inquire for ourselves, and deduce such inferences 
as the phenomena we have seen will justify. We have seen an 
irritating cause applied to the part, producing inflammation ; and 
that part, too, we have seen in some cases more susceptible of 
impression from the debility occasioned by a former attack; 
but this is not essential, as inflammation is produced without 
such preparatory condition of the part. As a child gets the 
croup, although it takes the disease more readily a second time, 
yet it has a first attack without any very peculiar sensibility of 
the part affected, with that alone which is peculiar to that early 
period of life. We have seen the phenomena of irritation or ex- 
citement in the part, the consequence of this irritating cause — we 
have seen redness, tumour, heat, pain, throbbing, vessels carrying 
red blood that never carried it before ; and those which before 
were scarcely perceived to convey red blood, now very much 
distended with it, and carrying more than the ordinary quantity 
of red blood, as in the vessels of the adnata, and those which were 
the subject of Dr. Wilson's experiments. We have seen these 
evidences of irritation not confined to the part, but extending to 
the vicinity and even to the whole system; but this is not all, we 
have seen again the whole system reacting in the part diseased — 
loading it with blood, carrying to it a quantity altogether dispro- 
portionate to the size of its small vessels ; and we have seen these 
small vessels under this extraordinary pressure, showing different 
terminations, according to the structure and functions of the part 
affected, the resistance it makes, and the cause keeping up the 
impulse. We have seen these inflamed vessels pouring out some- 
times blood — serum — pus — a gelatinous effusion becoming the 
medium of adhesion between the part originally inflamed and the 
neighbouring parts ; and we have seen the more sensible parts of 
the body ending in sphacelus. From all these facts we are 
authorised to conclude that the proximate cause of inflammation 
is a preternatural accumulation of blood in the part affected, ex- 
citing local or general irritation, according to the structure and 
sensibility of the parts and the nature of the remote causes and 
the time of their application. Observe, every temporary accumu- 
lation is not the proximate cause of inflammation; but kept up, it 



412 LECTURE XXXIII. 

will become so. General exercise quickens the circulation — par- 
tial exercise or the irritation of the part — mere friction from a flesh 
brush will increase for the time the quantity of blood in such 
irritated part ; but even that partial excitement will, if continued, 
excite inflammation. Scratching, friction, will excite inflamma- 
tion. General exercise will create general inflammatory fever; 
that is, inflammation of the whole system or synocha. Such is 
the best view I am enabled to take of the subject. It is the only 
one which in my opinion will explain the phenomena we have 
seen, and I believe it is the only one which will lead us to rational 
indications of cure, and the most effectual means of fulfilling those 
indications.* 

* I perceive Dr. Good has come to nearly the same result. " Inflammation," 
he observes, " consists in an increased impetus and accumulation of blood in the 
vessels affected, accompanied with a proportionate swelling and sense of heat." 
(See Study of Med. vol. ii. p. 228.) This I consider as a strong confirmation of 
the views and doctrines which I have taught in this College from its first esta- 
blishment, implying an increased momentum ; that is, an increase of quantity or 
weight multiplied into its velocity. 



413 



LECTURE XXXIV. 

TREATMENT OF INFLAMMATION. 

From the view which has been taken of the proximate cause 
of inflammation, seeing that it consists in an inordinate quantity 
of blood, and the increased velocit)^ with which it flows into the 
part, the seat of the disease, creating both local and general irri- 
tation, the following indications may be derived: 1st. To dimi- 
nish the quantity of blood circulating in or obstructing the part 
affected ; and, 2dly, thereby to prevent the debility, the effusion, 
whether of blood, serum, or coagulable lymph, the adhesion of 
parts, or the sphacelus, which such obstruction has a tendency to 
create. But it is to be remarked that there are two stages of in- 
flammation, viz. the acute and the chronic, the active and passive, 
tonic and atonic, and that the means of fulfilling the indications of 
cure will accordingly differ in those two stages, at least they will 
differ as it regards the extent to which the remedies indicated are 
to be employed. The means of fulfilling the first indication, that 
of diminishing the quantity of blood circulated upon the part 
affected, and consequently of lessening the momentum with which 
it is circulated, are the following : 1. The removal or avoidance, 
as far as possible, of the remote causes, whether predisposing or ex- 
citing, if they are still present and operating upon the system, or 
upon the part, the seat of irritation, as in ophthalmia, the foreign 
body must be removed, the syphilitic matter must be counter- 
acted. 2. By bloodletting, general or local, which both lessens the 
quantity of blood, and the force or impetus with which it flows ; 
for the momentum and quantity are generally in proportion one 
to the other ; or, to speak more accurately, the momentum con- 
36 



414 LECTURE XXXIVo 

sists of the quantity multiplied into the velocity. This evacuation, 
too, is especially important, when the inflammation is seated in 
parts of the body possessing great sensibility, or in parts intimately 
connected with life, for the reason already assigned, because more 
violent, and thence more rapidly exhausting the vital principle. 
But, in the use of this evacuation, we must observe some caution, 
regarding, not only climate, season, constitution, time of life, stage 
of the disease, &c, but the character of the disease itself, as in 
the local inflammation sometimes attendant upon typhus fever. 
But in recent injuries, the system, being under no other influence 
than pure synochal fever, or a purely local injury, bloodletting 
may be used with the utmost freedom, local and general, by open- 
ing a vein, or the division of an artery, or by the various modes 
of local bloodletting, by leeches, scarification, and cupping. In 
such cases, remember, 

"A little bleeding is a dang'rous thing, 
Eleed free, or open not the vital spring." 

3d. Other evacuations are indicated, not only with the same 
intention as bloodletting, but for the purpose of transferring ex- 
citement, and changing the determination or current of the fluids 
from the part affected to the exhalent surfaces, upon which those 
remedies are to operate. Active cathartics, such as the saline, or 
calomel and jalap, have a double operation in this respect. They 
not only act as so many lancets, or trocars, drawing off the fluids 
of the system, but they create new and strong impressions, new 
places of rendezvous ; they divert the enemy from the part they 
are ravaging, and attract them to other and new objects of atten- 
tion; we thereby, too, create new determinations upon parts 
where such irritation is relatively safe. This is an important idea 
to be kept before us, especially when the disease is seated in parts 
of great sensibility, either naturally so, or when acquired by dis- 
ease, as in a pleurisy or an inflammation of the brain. Boyer, 
in cases of this nature, to our great surprise, trusts to the "lave- 
mens," instead of active cathartics ; the advantage of cathartics in 
this respect is very apparent. 4. Upon the same principle, we 
employ sudorifics, i. e. such of them as at the same time that they 
effect this evacuation, do it without adding to the general excite- 
ment of the system ; on the contrary, which operate by relaxing 
the body, by unlocking the secretions, and, at the same time, re- 
tarding the circulation. Antimonial preparations, either in the 



TREATMENT OF INFLAMMATION. 415 

form of emetics, producing full vomiting, or in nauseating doses 
of that metal, are here indicated. Boyer objects to vomiting, yet 
he approves of venesection, because it relaxes ; but, I ask, is not 
relaxation the principal effect we expect from antimonial medi- 
cines ? Emetics are in many instances adviseable, particularly 
after other evacuations by venesection and cathartic medicines 
have been premised, as in cynanche trachealis, maligna and ton- 
sillaris, but not in phrenitis, gastritis, or enteritis ; of these here- 
after. In the latter cases, antimonial preparations in nauseating 
doses are to be preferred, as James's powder, the antimonial solu- 
tion, the union of tartarised antimony and the super tartrite of 
potash, (viz. 3ij cream of tartar, and tartar emetic gr.ij M., divide 
in pulv. viii. one every two hours. ) Some prefer the combination 
of the antimonial powders with calomel, but if the latter be im- 
proper in inflammation, the combination certainly will not justify 
the use of it, except only as a cathartic. The sp. minder, with a 
small quantity of laudanum, is an excellent sudorific, or the citrate 
of potash, or the Dover's powder may be employed ; opium, not- 
withstanding its supposed stimulant effect, you will find particu- 
larly proper after evacuations by the lancet, for the purpose of 
diminishing the pain and excitement attendant upon inflammation. 
Professor Reichter, of Gottingen, is a warm advocate of opium, for 
the purpose of subduing irritation in all inflammatory diseases ; 
for even pain becomes an additional and aggravating source of ex- 
citement in such diseases. Ware, too, in ophthalmia, pursued the 
same practice. Dr. Post also, in his own person, frequently divert- 
ed inflammation from his lungs by the use of opium. 5. Blisters 
are also adviseable, by translating irritation from important parts, 
the seat of inflammation, and are useful by the new excitement 
they create upon the surface ; with this view they are among the 
most valuable remedies to be employed. Sinapisms are also 
sometimes advantageously applied, upon the same principle. 
6. Diuretics are in some eases prescribed with benefit, especially 
such as sensibly diminish the excitement of the system, as the 
nitrate of potash gr. x. or xv. every two or three hours, and per- 
haps digitalis, if this plant be ever safe or useful. But this poison, 
on account of its deleterious effects upon the brain, is to be admi- 
nistered with great caution ; indeed, it may be dispensed with 
altogether, for you have abundant means of diminishing arterial 
action, without producing the deleterious and narcotic effects 



416 LECTURE XXXIV. 

which this medicine creates upon the brain, by which it effects 
the object of retarding the circulation ; its sedative operation is 
doubted by Orfila, which induces me to doubt the correctness of 
his observations in general, not only upon this, but other subjects. 
7. Local applications, which are calculated to lessen the activity 
of the circulation, are also to be permitted. In cases of violent 
local injury, in which a rupture of vessels takes place, and an effu- 
sion in the cellular membrane is the result, it is a good practice to 
empty the part by the lancet. I mean where the extravasation is 
very considerable, and more than- the absorbents can readily take 
away. I know a case in which the blood was discharged with 
great benefit ; whereas, when such blood is permitted to remain, 
it becomes coagulated, and afterwards undergoes a great change 
in its properties, and produces disease of the parts beneath, analo- 
gous to the retained menses behind the hymen. (See Smellie.) I 
have seen two cases in which an injury was sustained by persons 
rupturing a blood vessel on the anterior part of the leg, by striking 
it violently against the sharp edge of a carriage stone; they were 
neglected ; the result was, the blood effused, acting as a foreign 
body created a good deal of disease and ulceration in the parts on 
which it lodged. I dilated them very freely with the bistoury, 
and dressed them as common ulcers. In another instance, where 
the tumor was very extensive, I introduced a seton, which had a 
similar effect in discharging the contents of the tumor, and in 
restoring the parts to a healthy state. 

To prevent these consequences therefore, it is a good rule im- 
mediately to open such tumour and to discharge its contents as 
soon after the accident as possible, then applying a compress with 
lead water, a cure is readily effected. Upon the same principle the 
application of leeches, scarification, and cupping, are also to be 
used where a particular part is surcharged with blood in a less 
degree, especially accumulations about the brain, the eye, the 
mammae, the testis. In the former, cupping is to be preferred, in 
the latter, leeches are the most effectual application. Lead water, 
that is, the solution of the acetate of lead, or Goulard's extract, is 
frequently had recourse to. In cases of recent inflammation it is 
certainly an excellent application, that is if applied at a moderate 
temperature ; but applied as it usually is, cold, it is in many in- 
stances objectionable, by producing pain, especially in inflamma- 
tion of secreting surfaces, or secreting organs, as the eyes, the 



TREATMENT OF INFLAMMATION. 417 

urethra, the joints, testicles. Cold water, vinegar and water, or salt 
and vinegar applied cold after recent injuries, I have ever ob- 
served to add to the distress of the patient under such circum- 
stances, and especially in strains of the joints to which they are 
usually directed by most practitioners, they are peculiarly inju- 
rious ; for they assuredly by their stimulant operation, add to the 
pain and to the stiffness of the parts to which they are so applied. 
Tepid applications, on the contrary, in the form of fomentations, 
are in my opinion, infinitely preferable, and are the remedies I 
usually direct ; they soothe the parts and allay the existing irrita- 
tion, and thereby diminish the flow of blood to the part affected, 
and are among the best means of effecting resolution of the exist- 
ing inflammation. But when the inflammation is removed and 
the parts remain debilitated, in that case cold applications, cold 
water and other stimulants to restore the tone, are indicated ; for 
cold water applied suddenly, as before remarked, is among the 
most powerful stimulants and restoratives to debilitated parts that 
we can direct. During the first stage of active inflammation, atten- 
tion should also be paid to the diet of the patient, and which, as 
ill synocha, should be very simple, and the least stimulating, 
Abstinence from animal food, from wine, and other stimuli, 
should be rigidly attended to; even in the quantity of bread and 
water, great moderation is to be observed — while lessening our 
fluids with one hand, let us not increase them with the other. 
Upon the same principle, too, we should enjoin the avoidance of 
all stimuli which are calculated to excite the system — as light* 
heat, noise, exercise of mind or body, should all be carefully 
guarded against. 

But, secondly, when inflammation is very far advanced, and 
considerable obstruction or congestion has been produced, espe- 
cially when seated in the yielding cellular and muscular fibre, the 
indication will be to promote effusion from the distended vessels; 
for it is now ascertained that the means already employed are in- 
sufficient, or perhaps we are called upon at that advanced degree 
of inflammation, that it is too late to expect benefit from their use. 
To promote such effusion or secretion of pus, from the congested 
vessels, we must have recourse to warmth and moisture combined, 
such as fomentations by means of flannels wrung out of vinegar 
and water, or an infusion of hops. The application of a warm 
poultice of bread and milk, or of ground flaxseed mixed with it, 
36* 



418 LECTURE XXXIV. 

or of the white lily roots, (the lilium candidum,) remarkable for 
their mucilaginous properties, and which, therefore, have proba- 
bly been so long in use — or a poultice prepared of the slippery 
elm bark, (the ulmus fulva, called also Americana, by Dr. Dyck- 
man, in his excellent Dispensatory,) or other American species — 
the seeds of the quince, (the Pyrus cydonia,) also make an excel- 
lent poultice — the pith of the Laurus sassafras also. Even to the 
inflamed eye, a poultice prepared of some of these emollient ma- 
terials, is one of the best applications that can be made to the part — 
it should be boiled to a jelly. Tepid drinks, taken frequently, 
are also calculated to aid such effusion, and indeed in some cases 
if these means be early made use of, they prevent a purulent dis- 
charge, by removing inflammation and effecting resolution. But 
great care is to be taken not to reduce the tone of the system too 
much, or you prevent the secretion of pus, as you would impair 
the secretory power of any other vessels of the body; for both 
the whole system and the part itself, are sometimes so relaxed 
and debilitated that the parts remain stationary, neither tending 
to resolution nor proceeding to suppuration. In such cases both 
general and local stimuli so far from being injurious, are advanta- 
geously directed. In such cases of torpor or inactivity, bark, 
wine, and a better diet are to be prescribed. In like manner the 
stimulant gums, different stimulating plasters, stimulant poultices 
composed of onions, or garlic, honey, spirituous fomentations, and 
various other substances are had recourse to for the purpose of 
exciting the parts to suppuration; but be cautions that you do not 
employ them in active as well as in passive inflammation — this is 
a common error. Spirituous fomentations and the infusion of 
stimulant and bitter herbs are oftentimes improperly employed in 
the first as well as in the second stage of inflammation. When 
abscess is produced, that is, the effusion or secretion of matter has 
actually taken place, the matter is to be discharged without delay, 
by means of a lancet or the knife. Opening by caustic is too 
tedious, and leaves a ragged ulcer behind it, which by the use of 
the lancet or scalpel, is to be avoided. Such collection, too, 
should be discharged before a great excavation may have taken 
place; for the absorption arising- from the stimulus of the foreign 
body, remember, is not confined to the parts nearest the surface, 
but as I have already told you, extends to every part of the parietes 
or walls of the tumour. 



TREATMENT OF INFLAMMATION. 419 

Again, it should be evacuated early, to prevent that debility, 
that laxity which follows long distension of such parts, and espe- 
cially those which are naturally of a loose and relaxed texture, as 
about the anus. In like manner, when seated near parts of great 
importance, it should be discharged as early as possible, lest such 
parts become involved in the disease, as abscesses situated near 
the larger joints, as the shoulder, or hip, or knee joint. In like 
manner, such discharges, too, will both be facilitated by continu- 
ing the poultice perhaps a day, or even two; and which will at 
the same time lessen the irritation occasioned by the wound made 
to evacuate the matter. But of all things avoid the irritation of 
the part occasioned by the common practice of pressing it after 
opening, and indeed, as most strangely advised by Dr. Thomas. 
This becomes totally unnecessary when the part has been properly 
and freely opened. When the contents of the tumour are com- 
pletely discharged, the next, the third indication will be to give 
tone to the debilitated parts, and to the whole system, where it 
also partakes of the debility that may now be produced. This is 
not only necessary for the purpose of preserving a healthy action, 
but to enable the parts to reproduce those materials which have 
been removed or destroyed, by the secretion or generation of new 
parts to supply such loss, and to fill the cavity created. For this 
purpose, tonics and stimulants are indicated, both general and 
local, bark, wine, porter, ale, milk punch, the most stimulant nour- 
ishments are the most effective means of building up the strength 
of the whole system, while stimulant washes, viz: soap and water 
with rum, or some other spirituous addition, or with the sulphate 
of lime, or stimulant ointments, aided by bandage or compress, 
are advantageously directed. Setons, too, to excite the surfaces 
of such collections as cannot be completely or safely laid open by 
the knife, may be employed. Stimulant injections may be substi- 
tuted, and are among the means of exciting the parts themselves 
to healthy action. The principles upon which this treatment of 
the different stages of inflammation is founded, are no less applica- 
ble to phthisis pulmonalis and other inflammatory diseases, than 
they are to the simple phlegmon seated in other parts of the body. 
Even in the secondary stage of inflammation, constituting cancer, 
the same doctrine is our guide. Hence we now find extraordinary 
virtues ascribed to the carbonate of iron and other medicines, as if 
they contained a specific antidote to that disease. In this disease 



420 LECTURE XXXIV. 

be careful to avoid the relaxing effects of long continued poultices, 
as you would do in other ulcerations — you would otherwise render 
the part an issue — as I have known to happen in the N. Y. Hospi- 
tal. I knew a case of a young mulatto woman that had a tumour 
of the breast for months — cured by the stimulant or alterative ef- 
fects of mercury, at the same time that mercurial ointment and 
a mercurial plaster, by its stimulant effect on the breast, totally 
removed the obstruction of the part affected — the mode of treat- 
ment lately introduced by Samuel Young, by means of pressure, 
partly by plasters, and in part by compresses of sheet lead, no 
doubt is founded upon the same principle. (See Thomas' Pract. 
p. 609.) A fourth termination of inflammation, viz: by the serous 
effusion of fluids, as in the cavity of the joints, deserves our notice. 

A dropsy of the part is produced by the large effusion which 
follows inflammation when seated in these secreting cavities. In 
this case we have oftentimes both increased exhalation and dimi- 
nished absorption combined ; a great determination to the part, 
and an inability in the absorbing and circulating vessels of the 
part to convey off the matter effused. Stimulating plasters, such as 
the composition heracleum gummiferum, the gum ammoniac, 
dissolved in the vinegar of squills, the stimulating ointment com- 
posed of tartarized antimony may be used. The same ingredients 
applied in the form of a wash ; viz. Z'\. tart, antimony; gss. sp. 
camphor; ifei. water, are well calculated to produce an active 
excitement upon the surface, and thereby to divert the tumor 
from the part within, and perhaps to excite the absorbents of the 
joint to an increased action. This last application was first made 
use of in angina pectoris. (See Lond. Med. and Phil. Journal.) 
It is now employed in the treatment of white swellings, rheuma- 
tism, &c. i 

2d. The repeated application of blisters to the part, has been 
attended with no less beneficial effects. In the case of a lad, threat- 
ening white swelling, the tumor was removed by blisters, follow- 
ed afterwards by the use of tonics, general and local. Another 
remarkable case also occurred of a respectable merchant of this 
city, who was relieved of similar dropsical affections of the joints, 
particularly of the knees and wrists, by the application of blisters. 
No less than twelve in succession were applied; but in that case 
he had been a cripple for three years. He now walks as upright- 
ly as one of us. Another stimulating application which I have 



TREATMENT OF INFLAMMATION. 421 

prescribed with good effect, especially in those chronic enlarge- 
ments of the joints, is the saturated solution of the muriate of am- 
monia in vinegar, as recommended by Benjamin Bell. In cases 
of inflammation, the ordinary gangrene, he particularly recom- 
mends this combination: his prescription is as follows: — Zi. of 
the sal ammoniac: ^ij. of vinegar; ^vi. of water. The following 
is preferred by many: gss. mur. ammo.; Ibi. vinegar or alcohol. 
But in the chronic cases I have referred to, the application should 
be stronger; viz. the saturated solution of the salt. But when the 
active inflammation is removed, i. e. all pain, heat, and tender- 
ness to the touch, and mere enlargement and relaxation remain, 
great advantage may be obtained by the application of cold water, 
or the application of rum or brandy, and the parts sustained by 
the flannel bandage. The same division of the stages of inflam- 
mation and its consequences, with the different treatment indicat- 
ed in each, is no less applicable in other inflammatory affections 
than in those of the joints, to which I have called your attention. 

But, fifthly. In case of sphacelus, after inflammation has sub- 
sided, as occasionally occurs after blisters have been too long 
applied, what is to be our treatment? 

1st. Remove the dead matter that may loosely cover the parts 
affected. This done, apply a stimulant .poultice of bark and yeast, 
or bark and spirits, to the parts, and let them be applied mode- 
rately warm: occasionally also, cleanse and excite the surface of 
the part by washing it with a strong solution of soap and water, 
with the addition of yeast or spirits; or make use of the sulphate 
of zinc or of copper ; or apply the acetate of copper, in the form 
of an ointment, to the blisters when sphacelated. In like man- 
ner, it is useful to burns, asuming that character. From gr. ij. to 
gr. iv. to §i. of simple ointment. In the Infirmary of Edinburgh, 
the rectified sp. of wine is generally made use of as the most use- 
ful application to mortified parts, and is preferred to the bark, as 
a local application. Dr. Kuhn made an experiment in the Penn- 
sylvania Hospital, upon a person, both of whose legs were mor- 
tified: to one he applied the spirits of wine, the other he covered 
with the powdered bark. The first was the best application. In 
a short time, if the system be supported by proper nourishments, 
and by the use of bark, bitters, and other tonics, a healthy secre- 
tion will soon take place, and throw off the sphacelated parts. 
The carbon poultice, viz. gij. of charcoal, finely pulverized, and 
mixed with the common poultice, is also useful for correcting the 



422 LECTURE XXXIV. 

foeter, and changing the character of such ulcer. The carrot poul- 
tice is made use of for the same purpose. The fermenting poul- 
tice is also an useful and active application; i. e. a poultice com- 
posed of meal, either Indian or oatmeal, or other meal, with a 
proportion of ground flaxseed meal, mixed with the infusion of 
malt, with the addition of fresh yeast to it, at the time of the ap- 
plication. Fermentation soon follows. This application, by its 
heat and moisture, and stimulant materials composing it, is among 
the most effectual means of preserving the tone of the parts, of 
exciting a healthy action, and thereby of separating the dead 
matter usually attendant upon sphacelated parts. When such 
separation may be effected, afterwards, as before directed, support 
the tone of the parts by bandages and other local stimulants. But 
if inflammation still continues to accompany this appearance of 
gangrene or sphacelus, the simple poultice should be renewed 
until such inflammation shall have subsided, and the line of sepa- 
ration between the living and dead parts become apparent. The 
gastric liquor of graminiverous animals has also been used by 
Dr. Harness with success, in arresting mortification, in separating 
the diseased parts, and in promoting healthy granulations. (See 
2d vol. of the Trans, of the Society for promoting Med. and 
Chir. Knowledge.) Dr. White, of Manchester, has recommend- 
ed, in cases of this sort, the use of musk and ammonia, to remove 
the irritation, the subsultus tendinum, and other distressing symp- 
toms, frequently attendant on the local organs and producing high 
inflammation and sphacelus, as the effect of punctures. His pre- 
scription consists of musk and ammonia, gr. x., each in bolus. 
Another means recommended by a late writer in the Med. and 
Phys. Journal, for the purpose of arresting mortification, is by 
sprinkling the parts twice a-day with the nitrate of potash, finely 
pulverised. Mr. Pott has also written a paper in praise of opi- 
um in mortification, especially that which attacks the toes ; i. e. 
that opium is useful in arresting the irritation and pain which 
continue the inflammation when seated in parts of so much sen- 
sibility as the toes, and which irritation probably continues the 
inflammation until it ends in the total destruction of those parts. 
In cases of this sort it is doubtless indicated for the purpose of 
removing the sufferings of the patient, at the same time that it 
exerts its salutary effects by the general relaxation and diminished 
circulation that ensue from its use. But it is certainly a good ge- 
neral rule, that opium is not to be employed until the force of the 



TREATMENT OP INFLAMMATION, 423 

circulation has been subdued by venesection, and other depleting 
means, and only where the inflammation is seated in parts of great 
sensibility, and thence producing an inordinate degree of pain. 
Hence you do not find Mr. Pott's prescriptions of opium made 
use of in other cases of inflammation and sphecalus, but when 
thus seated in highly organized parts. In violent inflammation 
of the eyes it has also been found serviceable. — Case of Mr. 
Hartshorn, subject to ophthalmia, in which he informs me he has 
arrested the disease in its forming state by taking a large dose of 
opium and camphor: op, gr. vi., camph. gr. iv. There is another 
form of mortification, denominated dry mortification, arising from 
the ossification and obstruction of the arteries of the toes, in which 
opium is of little use, and which is only to be removed by early 
amputation. In such cases, Dr. Mott states he has sometimes 
found this practice useful. Dupuytren, on the contrary, is op- 
posed to amputation, under such condition of the system, believ- 
ing that the whole system labours under some general affection 
that produces such obstruction of the arteries. A very question- 
able practice has been recommended by the late Dr. Peiffer, and 
adopted by Dr. Physic; that of blistering mortified parts. This 
practice has more the air of novelty than real usefulness to re- 
commend it. They can certainly be of no other use than as sti- 
muli to the parts, or to the whole system. But these effects we 
derive from the antiseptic and tonic applications of yeast, bark, 
spirits, and the fermenting poultice; and we may add, the pyro- 
ligneous acid. May not the pyroligneous acid be advantageously 
employed as an external wash in typhoid fevers, as well as the 
acetous acid? Whereas, you have not only the stimulant opera- 
tion of the cantharides, but a new inflammation, which, like 
the first, may add to, instead of diminishing the evil. For 
the same reason that scarifications, in such cases, have been laid 
aside because of the fresh inflammation they create, I should 
question the propriety of applying blisters. Dupuytren uses the 
actual cautery to excite the surface of sphacelating parts. Astley 
Cooper employs the wash of the nitrous acid and water, 3i. to a 
quart. But the most formidable state of gangrene and sphacelus 
in the form of carbuncle, and that, too, under the most unfavoura- 
ble circumstances, yield to the treatment I have recommended, 
and as such I shall continue to employ it; together with the free 
use of bark, wine, and other stimulants and tonics, while the de- 
bility of the whole system, or of the part, may continue, 



424 



LECTURE XXXV. 



PHLOGOSIS. 



Phlogosis, Dr. Cullen defines to be pyrenia, partis externa^ 
rubor, calor et tensio dolens. This genus he divides into two 
species: 1. Phlegmone; 2. Erythema, in which he includes the ery- 
sipelas of authors. But Dr. Cullen is not satisfied with this arrange- 
ment ; he not only includes erysipelas here as a species of phlogo- 
sis, but in his order of exanthemata he again makes erysipelas a 
genus, besides including it under the species of phlogosis, viz : 
erythema. Rather let us make them, as they should be, three dis- 
tinct species of phlogosis: 1. phlegmone, 2. erysipelas, 3. anthrax. 
1st. Phlegmone, which Dr. Cullen defines thus: rubore vivido ; 
tumore circumscripto ; in fastigium plerumque elevato, saspe in 
apostema abeunte ; dolore saepe pulsatili. Yet he strangely believes 
all distinctions of inflammation founded on the structure of the 
parts, the seat of inflammation, to be altogether visionary ; absolute 
folly ; inepta ! 2d species, erythema, the erysipelas of authors, he 
thus defines : phlogosis, colore rubicundo, pressione evanescente, 
ambitu inaequali serpente, tumore vix evidente, incuticulae squamu- 
las, in phlyctsenas vel vesiculas abeunte ; dolore urente. Here, 
again, according to Dr. "Cullen, such distinctions are visionary. A 
man must indeed have a singular abhorrence to correct reasoning 
that can thus violate his own principles in almost every page. Un- 
der this head of erysipelas, or erythema, he includes anthrax or car- 
buncle, as the more violent form of erysipelas, the erythema gan- 
grenosum of Sauvages. But there are so many peculiarities, as we 
shall see, in the carbuncle or anthrax, that I am inclined to sepa- 
rate it both from the phlegmone and erysipelas ; more especially 



PHLOGOSIS. 425 

too, as requiring a particular and distinct treatment, and different 
in some degree from either. Phlegmone we shall find to be. 
seated more immediately in the cellular membrane ; erysipelas in 
the skin, rarely extending to the cellular substance ; but anthrax 
includes both as its seat, at the same time that it most usually in- 
volves even the fasciae of particular parts of the body, as those 
on the back of the neck, on the loins, and on some parts of the 
extremities. So far, then, they differ in their seat: but erysipelas 
we shall find to extend over the whole or any part of the body, 
but affecting the skin alone, while anthrax is local; though in its 
course, and in the fever which attends it, it involves the whole sys- 
tem, yet it has, where it terminates favourably, the suppuration of 
phlegmone, but like erysipelas it has great tendency to sphacelus. 
Hence it may be considered as a compound both of phlegmone and 
erysipelas, but having characters sufficiently peculiar to constitute 
it a distinct species. Dr. Cullen notices, but very unnecessarily, 
the various terminations of phlogosis, or local inflammation, under 
different heads; viz. 1. Suppuration or apostema, (read these in his 
Nosology,) " post phlogosin, remittentibus dolore et pulsatione, 
tumor albescens, mollis, fluctuens, pruriens." 2. Gangrene, the part 
livid, soft, little sensibility, and vesicles pouring out ichor; " post 
phlogosin, pars livens, mollis, parum sensibilis, saepe cumvesiculis 
ichorosis." 3. Sphacelus, the part black, flaccid, easily torn, with 
loss of sense or heat, and with the fcetor of putrid flesh, the cor- 
ruption or destruction spreading rapidly; "pars nigricans, flaccida, 
facile lacerabilis, sine sensu vel calore,et cum foetore carnis putridae, 
vitio celeriter serpente." These two last are mere grades of death 
in the part, and the whole of these terminations are but the symp- 
toms of phlogosis, and should make a part of its history, but do 
not call for the distinct notices bestowed upon them separately in 
Dr. Cullen's Nosology. 

Phlegmon, the first of these species, falls first under our atten- 
tion. This species of phlogosis, as I remarked, is seated in the 
cellular membrane, and exhibits a train of symptoms similar to 
those already noticed when speaking of inflammation in general. 
Phlegmon we may define to be a tumor, circumscribed, painful, 
red, and elevated, for the most part, to a point or top, terminating 
sometimes in resolution, most frequently in suppuration, and oc- 
casionally in sphacelus; depending upon the seat of it, and the 
nature of the cause producing it. Its causes have also been em- 
37 



426 LECTURE XXXV. 

braced in our view of inflammation in general. Our indication in 
phlegmon is, in the first or forming stage, to effect the resolution 
of it, if possible, and especially if it be seated in very important 
parts ; this is to be attempted by the means already pointed out, 
viz: 1. by evacuations, venesection, leeches, cathartics, antimonials; 
2. by blisters; 3. local sedatives, as the lead water poultice, lead 
water and laudanum, (excepting when such inflammation is seated 
in secreting surfaces.) In all cases these applications should be 
employed of a moderate degree of warmth, not cold, as recom- 
mended by Thomas, and indeed by most writers. Fomentations 
of vinegar and water are also among the best applications for effect- 
ing the dispersion of such tumors, especially in the mammae and 
testis. But, secondly, if the tumor be so far advanced as to give you 
no reason to expect its dispersion, you are next to promote the 
formation of matter in the manner already pointed out, and to dis- 
charge it as soon as possible by the lancet or scalpel. Do not leave 
it to discharge itself, for, as already remarked, you will have a 
tedious ulcer, and one in some cases attended with great inconve- 
nience, as in the inflamed breast, and in other cases attended with 
real danger, as when seated near an important joint. Should the 
tumor be large, and so seated that you are in danger of dividing 
important vessels, nerves or tendons, if by pressure or stimulant 
compresses you cannot excite the parts to healthy action, and 
destroy the fistulous state of the parts within, or stimlant injec- 
tions fail, make use of the seton ; this not only effects a complete 
discharge, but it also stimulates the diseased surface, and thereby 
promotes the healing process. The matter being thus freely 
discharged, the second stage having arrived, in which all inflam- 
mation is removed, the next object is to restore the tone of the 
part, and of the whole system ; not only for the purpose of filling 
up the cavity created, by the generation of new flesh, but so to 
invigorate the whole system as to diminish that sensibility to 
fever, which is, otherwise, at the time likely to ensue, from the 
absorption of pus. I mean hectic fever, and which I contend never 
arises from any other source, but that analagous to fevers from irri- 
tation, the effects of acrid matter in the blood vessels, as in the 
typhus, scarlatina, and various other eruptive diseases, so this is 
caused by and contined by the presence of pus, whether the pro- 
duce of an ulcer or the soft parts of the core. Hence Dr. Cul- 
len considered it as always symptomatic, and did not give it a 



ERYSIPELAS. 427 

place under fevers properly so called. We find the matter of the 
different contagious diseases to produce fevers of a peculiar cha- 
racter: so purulent matter begets its peculiarites, producing gene- 
rally two paroxysms in the twenty -four hours, about mid-day and 
midnight; and accordingly you perceive that when such matter 
is freely discharged, hectic fever is readily removed. But even 
where absorption of pus takes place, fever is frequently pre- 
vented or diminished by the use of tonics and stimulants, viz: 
bark, elix. vit, bitters, &c, and sometimes by opiates, as Dover's 
powders, with a nutritious diet, such as animal food, the liberal 
use of porter, ale, wine, &c These remedies I remark are fre- 
quently too long neglected, not only to the waste of the whole 
system, but that in some instances the sphacelus of the part is also 
the consequence of the general debility induced. Hence, there- 
fore, when matter has been formed and discharged, we cannot too 
industriously make use of both local and general stimulants and 
tonics, to bring about the healing process in the part as well as to 
improve the state of the whole habit ; both the local and general 
means of accomplishing these objects have already been particu- 
larly enumerated. In case of gangrene or sphacelus occurring, as 
we know by the blister appearing on the part, the remedies have 
also already been noticed, viz: bark, wine, the yeast poultice, the 
fermenting poultice, the infusion of malt with yeast and oatmeal, 
or strong beer mixed up with these last materials. 

The second species of the genus phlogosis, in the arrangement 
we have adopted, is erysipelas. The word comes from sqvcj, to 
draw, and 7te%a$, adjoining, because it involves the neighbouring 
parts. Dr. Cullen places this disease among his exanthemata; 
but he also notices the same when entirely local, and confined to 
the skin, without an affection of the whole system, under the head 
of erj^thema, making it a species of phlogosis, while that more 
formidable shape of the same disease, in which the whole system 
is affected, he places among his exanthemata or eruptive diseases. 
This distinction is certainly not well founded ; and indeed you 
will find, under his erythema, the most malignant form of erysi- 
pelas described by authors ; nay, under the head of the milder ery- 
thema he also includes among his synonyms the still more malig- 
nant affection, both of the skin and of the whole system, called 
carbuncle or anthrax. This, surely, is inconsistent with correct 
arrangement Although I have retained the arrangement of 



428 



LECTURE XXXV. 



eruptive diseases as adopted by Dr. Willan, and you find erysi- 
pelas among them, that I might not violate the integrity of his 
order, certainly the most proper place for erysipelas, which is 
not to be considered an eruptive disease, but is rather a pure 
inflammatory disease of the skin, is among the phlegmasia^. I 
have accordingly made it, as you will recollect, the second 
species of phlogosis, for the purpose of distinguishing it from its 
fellow members of the same family, phlegmone and anthrax. 
The first of which is seated in the cellular membrane — the last 
in the skin and cellular membrane combined, while erysipelas 
chiefly confines itself to the skin alone; and they all occasionally, 
however, like other inflammatory diseases, transgress their seve- 
ral limits; that is, phlegmon runs into erysipelas, and erysipelas into 
anthrax. But when erysipelas extends beyond its ordinary limits 
into the cellular and adipose membrane, in that case the inflamma- 
tion beneath is the effect — the effect too, of bad management. But 
it is not an essential part of the disease; on the contrary, so far 
it is a departure from the original character of the complaint, and 
which erysipelas derives from the pecular organization of the 
skin, viz: its- dense texture beset with small sebaceous glands and 
exhalents, which appear in a peculiar manner to be the seat of the 
disease. Dr. Cullen defines erysipelas to be an inflammatory fe- 
ver of two or three days; in general with drowsiness, often with 
delirium, affecting some part of the skin with an inflammatory 
erythema, but most frequently the face. Synocha duorum vel trium 
dierum, plerumque cum somnolentia, saepe cum delirio, in aliqua 
cutis parte, ssepius in facie, phlogosis erythema. Observe, in 
shingles oftentimes there is little or no fever, and very rarely, if 
ever, delirium. He divides it only into two species, the vesicu- 
losum, ending in large blisters, including rosa, that is, erysipelas 
of the extremeties, and sideratio, as it appears on the head and 
face ; and the second species, phlyctasnodes, which consists not 
of large, but many small pimples or spots, and which end also in 
small blisters or vesicles, and are for the most part confined to the 
trunk of the body. Under this species he describes the shingles, 
being a corruption of the French term, ceingle, a belt or girdle, 
or zona ignea of Hoffman and others — so called because it sur- 
rounds the waist like a belt; the eruption in some instances reach- 
ing entirely round the body. But Dr. Cullen has great doubts 
whether this species, the phlyctsenodes, is at all different from 



ERYSIPELAS. 429 

the first, the vesiculosum. Dr. Cullen also suggests the possi- 
bility of there being an inflammatory and a putrid erysipelas; but 
that of this he is not satisfied to say whether these two species 
should be formed; he very justly observes that as in hot climates 
the putrid diathesis exists, and in the cooler climates that the in- 
flammatory diathesis prevails; so in like manner the same disease 
may accordingly have different tendencies to the one or the other 
depending on these circumstances. There is doubtless some 
foundation for this distinction as far as a septic tendency will 
aggravate the symptoms of erysipelas. Accordingly it happens 
that in an impure atmosphere, as on board of ships crowded with 
men, and in hospitals, there is not only a great tendency to ery- 
sipelatous inflammation from the slightest wound, but erysipelas 
also readily assumes the typhoid character; and hence, too, it has 
been said to be occasionally in hot climates, a contagious disease. 
Thomas, in St. George's Hospital, Dr. Parr, also see Good, vol. 
ii. p. 646—7. Willan, Dr. Wells, Pitcairne, Baillie. In the Guer- 
riere it has been observed, in her late voyage to the Meditera- 
nean, that notwithstanding the free use of fruits and vegetables, 
such was the habit of body induced, that in every person on board 
who received the slightest wound or fever, it assumed immedi- 
ately a malignant character. But from the very texture of the 
skin itself, even in temperate or cold latitudes, there is a great 
tendency to sphacelus and the typhus type of its fever; and Dr. 
Cullen very properly, himself, remarks in the same note, that 
erysipelas oftentimes carries with it somewhat of a gangrenous 
nature, ("hie tamen notandum est erysipelas ssepe aiiquid putridae 
et gangrenosa^ indolis cum se ferre.") I divide this disease into 
four varieties. 

1st. Sideratio as it appears upon the head and face, and which 
is the most troublesome, the most tedious, and the most danger- 
ous; for in this eruptive disease, as we see in small pox, not 
only the eruption is greatest about the head, but such is the deter- 
mination to the head, that not only all the external parts become 
highly loaded with blood, and all the features swelled or dis- 
torted, but the brain itself becomes severely affected, either by 
stupor or delirium; and sometimes hydrocephalus is produced, for 
the carotids cannot carry an inordinate quantity of blood to the 
scalp, without also conveying a disproportionate quantity to the 
brain, being both branches of the same trunk. An important in- 
37* 



430 LECTURE XXXV. 

ference from this is, that in affections of the brain, as phrenitis, hy- 
drocephalus, apoplexy, our blisters will be more properly applied 
to the distant parts of the body, or between the shoulders, than to 
the head itself. 

2d. Zona, or belt, or shingles, which appears upon the trunk of 
the body, and chiefly about the waist, and like herpes, gradually 
multiplies itself to such an extent as to reach entirely around the 
body, which among the vulgar it is supposed to be attended with 
great danger. According to Dr. Darwin, this form of the disease 
frequently denotes an obstruction in the liver or some other of 
the viscera — this is not always true — for it frequently arises from 
a check of the perspiration alone; hence, it is common in the 
autumn, especially in plethoric habits. 

3d. Rosa — the erysipelas of the extremities, and which we most 
usually see, as connected with the gouty diathesis and old age. 

A fourth variety is the symptomatic, that is, attendant upon 
other diseases, as fevers, as miliary and typhus fever. It is 
frequently symptomatic, too, of affections of the stomach and 
bowels from indigestion, symptomatic of teething, and of ob- 
structed perspiration, especially in the heat of summer, or after 
violent exercise. This form shows itself in different parts of the 
body, and frequently in patches or weals. These also appear sud- 
denly, and are as suddenly removed ; whereas the varieties before 
mentioned, are of longer duration. The symptoms of erysipelas 
or St. Anthony's fire, more especially as it appears in the more 
formidable shape of sideratio, are : 

1st. The symptoms of inflammatory fever, viz: chills, suc- 
ceeded by general excitement of the system, a quick, hard pulse, 
hurried respiration, tongue white, much thirst, the skin unusually 
red, and attended with a sense of itching and sometimes burning; 
the surface, too, is remarkably dry as well as hot, and perspi- 
ration is not easily induced, resembling in this particular, the 
locked state of the excretory vessels that we meet with in scarlet 
fever. The whole system being powerfully excited, in a short 
time an elevation of the parts of the surface most affected is per- 
ceived, and an increased secretion from that part of a thin sharp 
acrid humour is now very apparent; fresh inflammation is ex- 
cited as well as an increase of the first; small vesicles are pro- 
duced, and in some cases a considerable discharge of a thin watery 
humour is manifest to the eye; but in some instances this is not 



PHLOGOSIS. 431 

perceptible, except by means of glasses; yet an irregularly spread- 
ing inflammation takes place wherever the fluid extends, and pro- 
bably beyond. It is however true that if wet or greasy applica- 
tions be made use of,, the inflammation is still more exten- 
sively diffused. A fatal angina in some cases ensues, when seated 
upon the neck and throat; or if in the head, such is the great flow 
to the brain that all the features become swelled and disfigured; 
the eyes in some instances are closed; but the irritation is not only 
external, the brain becomes oppressed by stupor; in some cases 
absolute phrenitis is induced. The disease thus continues for eight, 
ten, twelve, or fourteen days; if it is not gradually removed by 
evacuation, and resolution effected, it terminates either in vesica- 
tions, foul ulcers, or gangrene, or it breaks down the system by 
effusion upon the brain, or ends in typhus, and thus proves fatal. 
Hence it has been observed that inflammation of the brain and its 
consequences have been found upon dissection after death in this 
disease. This inflammation never ends in suppuration, or it 
ceases to be erysipelas. Suppuration, says Pearson,* is never 
seen in genuine erysipelas; but it has a constant tendency to gan- 
grene and sphacelus. Erysipelas, as I remarked before, derives 
its peculiar character from the very highly organised and dense 
texture of the skin, and of the infinitely numerous glands with 
which it is supplied independent of its excretory vessels, the func- 
tions of all of which are probably diseased in erysipelas. In conse- 
quence then of its great sensibility, and its numerous nerves, we 
are not surprised at the tendency of this disease to gangrene. 
But suppuration sometimes attends it when it involves the parts 
beneath, as in anthrax. I have seen a case of cedematous effusion 
in the cellular membrane beneath, enlarging the neck and dis- 
tending every feature of the face. The predisposing causes of 
erysipelas, are: 

1st. Certain temperaments, and especially the sanguineous and 
the nervous. Females are more liable than males; and children than 
adults, owing partly to their greater sensibility of habit. Hence, 

too, it appears more in certain families. Capt. G d's family, 

of the sanguine temperament, are subject to it, father, son, and 
daughters, and most usually every autumn. The same sensibility 
too, that is occasioned by one attack, predisposes to a second, &c. 

* Principles of Surgery. 



432 LECTURE XXXV. 

2d. A plethoric state of body predisposes to erysipelas; hence 
it frequently attends upon pregnancy — hence, too, it follows a 
sudden suppression of the menses, or is the consequence of their 
natural cessation. Women giving suck whose menses are sup- 
pressed, are frequently the subjects of erysipelas, especially upon 
being heated by exercise. 

3d. A vitiated state of the fluids, this was the opinion of Hip- 
pocrates and Galen. Tissot, too, ascribes erysipelas to the state 
of the blood, and to the want of due discharges by perspiration, 
in like manner it is frequently the attendant on chronic rheuma- 
tism. And it is the effect of old age, in which case both the ple- 
thora of age and the vitiation from the diminished excretions 
usual in advanced life, are probably combined. The exciting 
causes of erysipelas are, 

1st. Cold, suddenly applied, especially when the body has been 
previously heated; a cold bath made use of when the body is in 
a state of perspiration, is a frequent exciting cause of this disease. 
Hence, too, erysipelas is the disease of autumn. 

2d. The suppression of the natural excretions by the skin, 
bowels, or the menses, from whatever cause such suppression may 
proceed, is another common cause of erysipelas. 

3d. Fever is another exciting cause of this disease; not only 
by means of the stricture upon the excretions which takes place in 
fevers, but also by the inordinate excitement of the blood vessels, 
such determination to the surface is both produced and aggravated. 

4th. The irritation attendant upon indigestion frequently ex- 
cites an erysipelatous inflammation on the surface, Lobsters, crabs, 
and other articles difficult of digestion, are fruitful sources of that 
disease. The effects of vinegar show the intimate connexion be- 
tween the state of the stomach and the surface of the body. From 
the connexion between this disease and the disturbance of the 
digestive organs, some writers, ancient and modern, have consi- 
dered this disease in some cases to be of a bilious nature, and 
have made a species of it, which they so denominated. Galen, 
among the ancients ; Desault, Richter, and Richerand, among 
the moderns. They therefore attach much value to emetics. (See 
Cooper's Surgery.) 

5th. The irritation of teething produces not only sore ears, or a 
strophulous on the cheek, but in some instances a general eruption 
and erysipelas, with a febrile state of the whole system, are the 
consequence. 



PHLOGOSIS. 433 

6th. Irritation of the skin itself, as by blisters, wounds, &c. is 
a frequent exciting cause. Blisters I have known to excite an 
erysipelas, which diffused itself over the whole chest. 

Sulphur, mercury, arsenic, the euphorbium, the fumes of the 
cashew nut, (anacardium occidentale.) Insects may also be in- 
cluded among the exciting causes of erysipelas. 

7th. Wounds, as gun-shot wounds; wounds, especially on the 
head, and scarifications employed in dropsy of the extremities, 
and especially the large incisions made by the lancet instead of 
slight punctures. 

8th. The distension of parts, as in dropsy, is sometimes fol- 
lowed by erysipelas, in the form of rosa; i. e. in the extremities; 
and that, too, not unfrequently ends in sphacelus, and proves 
fatal. 

9th. Heat, as the direct rays of the sun, not only in the trop- 
ics, but even in our temperate climate. Burns, and scalds. 

10th. Intemperance in the use of spirituous liquors. 

The phenomena which we have noticed to characterise this dis- 
ease ; viz. the white tongue, the frequent and tense pulse, the hot 
and dry skin, and great thirst, all announce it to be, especially in 
the first stage, a pure inflammatory disease. The causes, too, both 
predisposing and exciting, lead to the same conclusion; and that 
it demands the treatment which we have observed is indicated 
in such condition of the system: guided, however, by the habit 
of body, the peculiar cause from whence it has proceeded, the 
part more immediately the seat of the disease, time of life, dura- 
tion of the disease. Venesection is called for where the disease 
occurs in a full, athletic habit of body, and has been occasioned 
by cold, or suppression of the natural evacuations, as of the men- 
ses, or in pregnancy. Venesection then is to be employed libe- 
rally, especially when the disease appears upon the head and 
chest. In like manner, the species called zona, when induced by 
change of season, is most effectually removed by the same reme- 
dy, inasmuch as it usually occurs in the full habit of body. To 
my great surprise, I perceive Dr. Good is not the friend of vene- 
section in this disease. He remarks: " Venesection was formerly 
recommended, and has been so, of late, by a few writers, but upon 
mistaken principles." "I can conceive," he adds, " very few 
cases in which it has a chance of being serviceable. " He then 
recommends gentle laxatives, and instantly after tonics, bark, &c. 



434 LECTURE XXXV. 

2d. Cathartics are, for the same reason, to be employed, as the 
saline cathartics. Dr. Friend appears to depend principally upon 
cathartics, even in the most violent forms of this disease. In a 
gouty habit of body, where the stomach is generally irritable, the 
preparation of rhubarb, magnesia, and mint-water may be prefer- 
able. In the erysipelas occasioned by teething cathartics are also 
indicated, especially magnesia. This, on account of the acidity 
which is predominant in the stomachs of children, at this period 
of life, is peculiarly advisable. I am also, on account of the febrile 
symptoms, much in the habit of directing the combination of 
small doses of ipecac, and rhubarb, aa. gr. i.; or gr. ij. M.: these 
are my favourite febrifuge, which I denominate my tooth-powders, 
or rather my teething powders. 

3d. In some cases of erysipelas, as that from the sudden check 
of perspiration, or from indigestible food, emetics are the most 
effectual means of removing the disease, and will be found useful 
in this disease in most cases, except where it arises from plethora 
or in a gouty habit of body. But remember, where a fulness of 
the vessels exists, and perhaps a determination to the brain, that 
emetics, by the mechanical effects of vomiting, in retarding the 
return of blood from the brain, are in such cases peculiarly dan- 
gerous. In old age they should on these accounts be avoided. 

4th. Antimonial and other diaphoretics are generally indicated 
in this disease; but, 

5th. What shall we apply to the parts affected? 

The best applications, in my opinion, are such as will not only 
defend the parts from the air, but which at the same time are cal- 
culated to absorb the acrid, watery fluid which is poured out from 
the inflamed glands and excretories of the skin, and thereby to 
prevent the disease from extending. Any moist application or 
ointment, I observed, is calculated to spread the inflammation; 
therefore let all such be carefully avoided. Chalk, starch, very fine 
wheat flour, or rye or oat meal, and hair powder, dried over the 
fire, are in my opinion the safest and the best applications for this 
purpose, and should be frequently renewed by means of a puff, 
removing at each application of the farina, such portions as may 
have been rendered wet by the discharge, which, in some cases, 
is very profuse. In this way powder the parts fifty times a day; 
a very good powder is half starch, half calamine. (See Good 
vol. ii. p. 616.) Blisters have lately been recommended by Dr. 



PHLOGOSIS. 435 

Dorsey and Physic, upon the authority of the late Dr. Pfeiffer, of 
Philadelphia, who is said to have introduced that practice; and 
which, both Physic and Dorsey advocate as the best mode of 
healing erysipelas. Dupuytren applies them in the erratic ery- 
sipelas; also the actual cautery! Delpech also states that he has 
frequently prevented suppuration or sphacelus by the early appli- 
cation of blisters. Where the brain is much affected by stupor 
or delirium, they will no doubt be found useful. Where sphacelus 
is approaching they may also be found beneficial; but I have ne- 
ver employed them. In some cases the farinaceous applications 
are said to be of but little benefit. In these cases, Dr. Thomas 
states that cooling lotions, as recommended by Cooper, (see his 
Dictionary of Surgery, and his First lines,) he has found of great 
benefit; and that, for this purpose, he has made use of the liquor 
ammonias acetatis and water, equal parts ; or muriated ammonia 
dissolved in water, with the addition of a little vinegar and cam- 
phorated spirit, with great relief to the feelings of the patient, 
when the farinaceous powders seemed rather to aggravate than 
soothe the sufferings attendant on this complaint. But where this 
is the case, I am fearful the vis a tergo has not been taken off by 
by the lancet and other means of depletion. But perhaps by the 
severity of the disease, or by the neglect of the depleting means 
recommended, you are called upon to prescribe for the parts alrea- 
dy arrived at the state of gangrene or sphacelus. Farina now will 
be of little use ; in such case, treat them by the same means which 
we have already recommended in sphacelus and gangrene from 
other causes, viz: by the yeast poultice, bark and yeast, bark and 
spirits, and the liberal use of bark internally. If the patient be 
young, he may still perhaps be preserved, but if in the decline of 
life, you have little to expect. Dr. Fordyce gave it in doses of 
3i. every hour ; he tried it for twenty years, and with growing 
confidence, says Dr. Good ; but he adds, (i when there is an even- 
ing exacerbation, some diaphoretic, as James's powder, is called 
for, or the sp. mind, with the spirit of sulph. aether ; or which 
is in my opinion preferable, the nitrous aether. Where the habit 
is much vitiated, as is frequently the case in old age, and in per- 
sons who have suffered much from chronic complaints, as gout or 
rheumatism, you will find great benefit in the ordinary erysipela- 
tous eruptions of such habits by the use of the decoction of the 
woods, composed of guaiac and sarsaparilla, i. e. after the use of 



436 LECTURE XXXV. 

some mild aperient. Lead water has been recommended, by Dr. 
Dorsey and others, as an external application which has been em- 
ployed with benefit in this disease. Dr. Thomas, in my opinion, 
very justly remarks that no solution of lead, copper, or alum, 
should be employed in erysipelas ; but if it be of service in re- 
moving the inflammation of erysipelas, it can only be so after the 
various means of depletion which have been enumerated have 
been previously employed; it will otherwise be a hazardous pre- 
scription; for even if we succeed in repelling such inflammation 
without previous evacuations, and the first cause of the disease be 
still operating upon the system,we only translate irritation from 
one part of the system to another, and perhaps to the brain, 
or some other organ intimately connected with life ; apoplexy or 
convulsions are, I believe, frequently thus produced. If eruptions 
or local irritation ever prove critical in fevers, so may the repel- 
ling of such eruption be the means of renewing fever, or of ex- 
citing some other irritation in the system; hence, then, the danger 
of suddenly suppressing local irritations, when they appear ; and 
especially when they may have been of some duration, and the 
system has become habituated to them. Two or three facts on 
this subject will at least teach us caution in the use of this remedy. 
In a case of an eruption behind the ears, from teething, I over- 
looked the cause; directed some mild aperient and lead water 
to the eruption; the inflamation was suddenly suppressed, fever 
was renewed with convulsions, which terminated in death. 
An habitual ulcer and irritation in the forehead, operating 
like an issue to the system, was removed in the same manner; 
but apoplexy soon ensued, and proved fatal. But in a case 
of erysipelas on the arm and chest, in an old gentleman, of 
this city, of full habit, where venesection was omitted, and 
wet applications of this nature were employed in the first 
stage, instead of the farinaceous wheat or rye; sphacelus en- 
sued and proved fatal. Look at erysipelas, therefore, as a 
disease of the whole system, and remember the great tendency 
to sphacelus, which inflammation manifests when seated in 
parts too highly organised. Nevertheless, there are cases in 
which, after the excitement of the system has been removed, 
the local irritation of the skin will continue ; in that case, lead 
water has in some cases been very advantageously directed. 
Magnesia, too, used in the place of lead water, is beneficially ap- 



ERYSIPELAS. 437 

plied without; a translation of the inflammation. The diet and 
regimen of the patient should also constitute a part of }*our pre- 
scription, and should be directed according to the stage of the 
disease. In the first stage it should be simple and plain, and chiefly 
composed of vegetable nourishments and acid fruits; the frequent 
use of diluents, to promote the secretions, should also be enjoined, 
especially the sub-acid drinks, as tamarind water, lemonade, cur- 
rant jelly and water, barley water, &c. But in the second stage, 
especially where gangrene is to be apprehended, the diet of the 
patient should be stimulant and cordial, with the liberal use of 
wine and porter, sago, arrow root, &c. The dress of the patient, 
air of the room, temperature of his drinks, should also be attend- 
ed to as in the treatment of inflammation in general. But should 
the typhoid termination of the disease, the erysipelas gangreno- 
sum of Willan, show itself instead of the inflammatory character 
with which it usually appears in this climate, you will, in that 
case, have recourse to the means we have so fully recommended, 
viz: bark, snakeroot, the mineral acids, and especially vegetable 
nourishments and the plentiful use of wine. There is another 
form of erysipelas noticed by authors, I mean the erysipelas in- 
fantum of new born infants. (See Underwood. ) One form Brom- 
field has described ; another form of it, as attended with varia- 
tions, and tending to gangrene. In it the external use of bark and 
spirituous fomentations are the chief remedies. Lead water was 
found by Dr. Garthshore injurious, by inducing sphacelus. Blis- 
ters also are injurious. (See Willan. See Thomas and Underwood.) 
But the spirituous applications have been more successful: both 
have been tried in the British Lying-in Hospital. Bark also 
has been given by injections. A third form called by Drs. Ham- 
ilton and Underwood, skin-bound, and by the French "endurcis- 
sement du chair, 7 ' is also occasionally met with, but I believe never 
cured. 



38 



43S 



LECTURE XXXVI. 



ANTHRAX, OR CARBUNCLE— THE THIRD SPECIES OF PHLOGOSIS\ 



Anthrax is a Greek word signifying a burning coal. Carbuncle 
comes from carbo, charbon the French call it. This disease, as I re- 
marked before, when dividing the genus phlogosis into its three 
species, appears to partake both of phlegmon and of erysipelas in 
many of its symptoms; k divides itself into two species. 1st. Idio- 
pathic anthrax, and 2d. symptomatic anthrax. It is symptomatic 
when it occurs in plague, in typhus, in yellow fever, or in other dis- 
eases. This subject has very early attracted the attention of physi- 
cians. Galen, in his work, De tumoribus, Celsus and Fabricius have 
all shown tkeir knowledge of this malignant form of inflammation, 
and by modern writers it has also been very minutely described; 
particularly by Wiseman, Bromfiejd, Kirkland, David, in the 
Academy of Surgery, by Pouteau, Pearson, William Fordyce, 
and by Willan and John Hunter. In the Medical Comm., vol. 
ii. pp. 34, 37, you will also find that it has received notice. But 
notwithstanding the attention that has been bestowed upon it, 
both by the ancients and moderns, there appears to be a great 
diversity of opinion relative to the mode of treatment which 
ought to be pursued in this disease. Having seen several cases 
of this tumor, some of which have ended fatally, and others have 
been treated with success, I shall now submit to you such obser- 
vations as I have been enabled to make on this interesting subject. 

Anthrax I define a hard circumscribed tumor, seated both in the 
skin and cellular membrane, accompanied w T ith a sense of burning 
and pain, (not the pulsation of ordinary phlegmon, nor is it con- 
fined to the skin as erysipelas,) of a livid purple hue, and early 
exhibiting the symptoms of approaching sphacelus, for such is its 



ANTHRAX. 439 

general tendency unless relieved by art. 1. It begins like a com- 
mon boil, having the circumscribed character of phlegmon; in the 
beginning too it has redness, great pain, with burning heat, but 
not the pulsation of phlegmon; sometimes a violent itching exists 
in the part. 2. In a day or two, for the inflammatory or active 
stage is comparatively of short duration, the tumor manifests a 
dark crimson red colour, particularly in the centre, but paler to- 
wards the circumference. 3. It soon shows a small pimple or 
pustule on the top, and at first view you may be inclined to think 
that the tumor is about to discharge itself at this point, and thus 
terminate. Not so : for the top being broken off, it is not well 
formed pus that is discharged, as in simple phlegmon, but a sharp, 
thin, brown liquor, a sort of bloody water, or sanies, and that 
without the least relief of its symptoms. 4. The swelling 
does not become very much elevated above the surface, but re- 
mains for a long time, say several days, hard and deep seated, 
attended with great stiffness in the neighbouring parts, and severe 
pain, especially on motion, and exquisite sensibility to the iouch. 
Like erysipelas, too, it has the burning heat of skin ; shows the 
skin to be much affected, and that too very early; manifesting 
throughout a dark reddish brown, or even a crimson, or a purple 
colour, and attended with great sensibility; like erysipelas too it 
exhibits a diseased and febrile condition of the whole system ; 
like erysipelas it is not inclined to end in pus as its natural termi- 
nation, as is the case with phlegmon ; like erysipelas too it is pro- 
tracted beyond the usual period of phlegmon, and much inclined 
to gangrene ; and like gangrenous erysipelas, says Dr. Willan, (p. 
497,) the swelling exhibits a dark red inclining to a livid hue. It 
shows, as I remarked, a febrile state of the whole system, and this 
fever, I should add, has a great tendency to the character of ty- 
phus. The pulse, very early in the disease, is weak and low, but 
frequent ; for the operation of the disease upon the system is 
severe, and the subjects of its attack are usually the aged and the 
feeble, and whose general health is more or less impaired by pre- 
vious disease, particularly eruptive diseases. An exception is 
mentioned by Tournefort, who states, in his Travels through the 
Levant, that it attacks feeble infants in warm climates, and proves 
quickly fatal ; he also describes it as endemic, in his day, among 
the islands of the Archipelago. The tongue is sometimes white, 
but frequently it is moist, and in some cases of a deep red colour, 



440 



LECTURE XXX7I, 



as in the advanced state of typhus fever; the patient is usually 
languid, showing great prostration of strength, and that, too, ap- 
pears early in the disease ; and such is the depression of the vital 
powers, that it is frequently difficult to excite the system, even by 
wine and cordials ; such, too, is the impression made upon the 
nervous system by this disease, that the patient very early mani- 
fests it ; sometimes it shows itself in great restlessness ; a general 
irritation and sense of itching over the whole surface of the body, 
and eruptions too are commonly attendants upon this excitement 
of the surface ; the patient also complains of frequent chills, and 
at the same time the skin is dry and hot. In other cases, instead of 
restlessness, I have known the patient to be remarkably drowsy, 
yet unable to sleep, owing to the pain and irritations of the system, 
and, in some instances, delirium appears within the first days of 
the disease. The nervous system also manifests the depression at- 
tending this disease, by palpitation of the heart, and a tendency 
to delirium. The appetite is bad, attended with great nausea and 
sometimes vomiting. These symptoms also are doubtless ascriba- 
ble to the intimate connexion which exists between the stomach 
and other sensible parts of the body; for any violent pain or irri- 
tation, as we have seen, especially when seated in organs of great 
sensibility, is readily communicated to the stomach ; this is no 
less expected when the skin is the seat of the disease, as in erysi- 
pelas, in eruptive diseases in general, and especially in the painful 
tumor now under consideration. The bowels are for the most part 
costive; but sometimes I have seen it succeeded by diarrhoea, and 
that in a very short time proceeding to a dangerous degree ; for the 
system, as I said before, is readily exhausted under the sufferings of 
anthrax. The tumor also, when the disease is about to terminate 
unfavourably, assumes in a few days a very dark colour; a black 
slough forms in the centre, and a sharp bloody humor is effused 
from that part of the tumor; vesications also show themselves on 
other parts of the swelling, indicating the general sphacelus of the 
part, that is about to ensue. 

But if the patient be well treated, or has strength of constitu- 
tion to give a favourable termination to the disease, the tumor, 
instead of the dark livid hue, the bloody sanies and vesications, 
denoting gangrene or sphacelus, exhibits a different character. 
It breaks out in many small holes, or little cells, through which 
pus of good quality flows. The tumor appears like a morass, or 



ANTHRAX. 441 

quagmire, of a spongy honey-comb structure, not altogether un- 
like the convex surface of a placenta, and upon pressing it you 
find it full of matter beneath and of considerable extent. Fre- 
quently, says Pearson, (Principles of Surgery, p. 308,) there are 
in this cellular texture little caverns, and intercurrent sinuses; 
and he adds, "that considerable sloughs are thrown off in 
masses;" i. e. I suppose he means, where sphacelus has been the 
consequence, for where a healthy pus is discharged, the fleshy 
substance of the part is not detached as where its texture is de- 
stroyed by gangrene. On the contrary, the whole mass becomes 
gradually condensed, as the parts beneath are filled up. The 
disease too at this time shows that it is not confined to the skin, 
but is connected with the cellular membrane and the subjacent 
parts. Indeed they appear united, and so intimately that each 
cell appears to find its exit by a corresponding aperture in the 
skin. The size of the tumor sometimes extends to six, eight, 
ten, or twelve inches diameter. It is also of long duration, say 
from three weeks to three months; very much, however, depend- 
ing on the manner of its termination. Where the destruction of 
parts does not take place by sphacelus, but a healthy pus is poured 
out, it usually heals in three or four weeks; not so where a large 
excavation is made by mortification of the part, and where for the 
most part the disease proves fatal. 

This leads me to notice the ravages of this dangerous disease. 
This disease is very generally traceable to a vitiated habit of 
body, especially of a scorbutic sort. The same idea is expressed 
by Bromfield, for he makes two kinds of anthrax, that from a 
great quantity of blood highly inflamed, and that the effect 
of a putrid and malignant fever; and speaking of these, he adds, 
" a bad habit of body from the vitiated state of the circulating 
fluids, which, producing fever of the most malignant kind, must 
always be attended with the utmost danger." (p. 120.) 

My observation has been that simple phlegmons, ending in 
large abscesses are the more common consequences of plethora 
when unattended by the vitiation of the habit before men- 
tioned. These, indeed, are not unfrequent from that fulness 
of the vessels alone, though in some instances they too are as- 
cribed to the supposed peculiar gouty humor floating in the sys- 
tem. But the anthrax we have described is not merely the effect 
of such fulness alone, but generally arises from an additional 
38* 



442 LECTtfRE XXXVI. 

vitiation of the system. In the first place, I observe, it usually 
appears in old age, when such change of the state of the system 
is most apt to occur. The greater number of cases which I have 
seen have appeared in advanced life; and where it occurred in 
women, it has been after the cessation of the menses, and in 
those too of a plethoric make and who have lived a sedentary 
life, and whose secretions had become more or less impaired; but 
in habits of this description you will also see it at any age. 2. I 
have observed that in all I have attended, they were more or less 
subject to eruptive diseases, especially to erysipelatous inflamma- 
tions. In the case of Mr. H — — -e the disease was preceded 
by, accompanied with, and followed by eruptions, and those of a 
very obstinate character. This too is an observation made even 
by Galen, that vesicular eruptions generally precede carbuncles. 
Galen De Tumoribus Prset. Nat. See Assalini, Neale's transla- 
tion, p. 54. The same idea is expressed by Willan, (that anth- 
rax like erysipelas, is attended with an extraordinary heat, creep- 
ing and pricking under the skin.) 



TREATMENT OF THE DISEASE. 

After what has been said of the time of life, and the vitiated 
state of the system in which this disease usually occurs, and the 
great prostration of the vital powers which appears to characterise 
it in its progress, you will be induced to believe that venesection 
is rarely indicated; indeed the circumstances which have been 
mentioned generally, forbid the use of the lancet, yet there 
are doubtless cases of great fulness, where it will not only be justi- 
fied, but may be absolutely necessary in the forming stage of this 
disease; but it must be done with due reference to the state of 
the system, as in other diseases in which local inflammation is 
conjoined with a vitiated habit of body, as in dysentery, typhus, 
cynanche maligna and puerperal fever, &c. Indeed we may 
denominate this tumor a typhoid phlegmon. In general, how- 
ever, you will trust to evacuations from the bowels and attention 
to the skin, particularly the latter ; and as the strength of the 
patient is early impaired in this disease, and the stomach irritable, 
the purgatives you employ should be such as are least offensive 
and least debilitating ; such as rhubarb and magnesia, an infusion 



ANTHRAX. 443 

of senna and manna, or castor oil, if they can take it; but let me 
recommend to you, with the view to the state of the whole system, 
as early as possible to induce perspiration, and to preserve the 
skin in this condition, for by such diaphoresis you both lessen the 
local irritation and counteract that general condition of the habit 
that appears to constitute an essential part of this disease. This 
should be accomplished by the use of warm bathing ; bathing the 
feet and legs in tepid vinegar and water, and by the ordinary 
warm drinks that have been directed in febrile diseases. If the 
stomach be not much disturbed, an ounce dose of the spiritus 
mind, and laudanum may be given, or the saline draught of Rive- 
rius, with advantage, during the first days of the disease; but in 
a short time you will have occasion to keep up such diaphoresis 
by wine whey or an infusion of the Virginia snake root, for as the 
tumor advances, its malignant character shows itself with a gene- 
ral typhoid tendency in the whole system. The applications 
which you will make to the tumor itself in the first or inflam- 
matory stage with most advantage, will be a soft light bread and 
milk poultice, fomentations of vinegar and water; a light vinegar 
poultice; cloths wet with the sp. mind, and laudanum; but lead 
water should be carefully avoided. Dorsey recommends blisters 
to the part as preferable to every other local remedy ; and after- 
wards the parts to be dressed with basilicon ointment, and if poul- 
tices are applied they are to be light, he observes, and frequently 
changed. But of blisters I have had no experience, but if useful, 
they doubtless must be so in the early forming stage of anthrax; 
in such case I believe they may be useful as in other tumors, 
but not in the last stage. The second stage of the disease having 
arrived, your object will be to obtain suppuration, that is, a heal- 
thy action of the vessels of the part. This can only be done at 
this time by stimulants and tonics, and these both generally and 
locally applied. It is most strange that writers should talk of an 
anthrax healing without suppuration, yet such is the language of 
Wiseman, of John Pearson, and countenanced by the Edinburgh 
system of practice in this disease. The best tonics to effect this 
object both of supporting the general strength and of causing a 
healthy action in the part, are the Peruvian bark, bitters, snake- 
root, and the mineral acids. The bark is to be preferred, and in 
substance, if the patient can receive it. William Fordyce recom- 
mends it to be taken in drachm doses, in conjunction with a few 



444 LECTURE XXXVI. 

drops of mineral acids every hour; this, for reasons advanced, 
when speaking of t) T phus fever, must be proper. The diet should 
correspond with the medicine prescribed; it should be both the 
most nutritious and the most stimulant; wine should be given ad 
libitum, and in every form, consulting the taste of the patient. 
Wine alone, wine whey, in the form of caudle or panada, or with 
sago, &c; brandy milk-punch is also, in some cases, preferable, 
being most acceptable to the patient. Soups, if the patient has an 
appetite for them, (but usually they have no appetite; on the con- 
trary they generally manifest the greatest disgust to animal food 
in every form in which it can be presented,) may also be given, 
especially strong beef tea. In some cases I have even given my 
patient eggs and oysters, where they have called for them, that 
is, when the patient is free from fever. Opium you will find in- 
dispensably necessary both to allay pain and to procure sleep. 
It is quite as useful here, as in mortification of the toes, as recom- 
mended by Mr. Pott, and for the same reason; for great pain 
and irritation is doubtless a means of increasing inflammation 
whenever it is seated in any highly organised and sensible parts of 
the system, and in which of course there is a great tendency to 
sphacelus. In this disease, accordingly I have found opium of 
infinite use, both administered through the day in small doses, 
and at night to procure sleep. The nitrous aether, or Hoffman's 
anodyne, or the tincture of hops in severe irritations may suffice 
to allay the sufferings of the. patient, or at least they will prove 
valuable auxiliaries for this purpose. The local applications in 
this stage of the disease should also consist of the most powerful 
stimulants, such as bark with spirits or yeast, or yeast alone, or 
spirituous washes and applications, or the yeast poultice, &c. as 
already noticed in the treatment of sphacelus, and when healed 
the part should be washed with rum to remove any remaining 
morbid sensibility. The decoction of the woods is also an ex- 
cellent drink to correct the general state of the habit. The occa- 
sional use of the warm bath, and attention to diet, will also very 
much contribute to the same end. From the cases I have treated 
I have come to the following inferences. 1st. That the treat- 
ment by lead water and the ordinary relaxing poultices and oint- 
ments made use of in simple inflammatory phlegmon, are injurious 
in anthrax and should be avoided, excepting in the first two or three 
days of the disease. 2d. That the stimulating and antiseptic ap- 



ANTHRAX. 445 

plications are called for and are found peculiarly beneficial. Ac- 
cordingly too, the cases which have ended successfully in this 
city have been treated by the last mentioned means, while 
those which have ended fatally have been treated by the anti- 
phlogistic system. Dr. Rush mentions another case cured by the 
same means. Extirpation has been proposed, and by others, as 
by Kirkland, Cooper, and the Edinburgh practice, it is recom- 
mended that the parts be freely dilated and discharged, as in 
phlegmon; but this practice, in most cases, becomes at least un- 
necessary, and as the parts have a great disposition to bleed and 
to sphacelate it must be certainly improper, or done with much 
caution. A case where the knife was so employed was followed 
by a fatal sphacelus. Another application that has been recom- 
mended is to cover the centre of the tumor with lime, and the 
edges with lint moistened with chalybeate wine, (see Edinburgh 
Practice,) but in my opinion bark and yeast are to be preferred. 
In the time of Galen the Falernian wine was made use of as a local 
application in wounds and in tumors of this description. It was 
no bad application. Rum is better. Arsenic recommended as 
early as by Agricola, and has been used in the form of orpiment 
and Plunket's caustic. Ledran preferred corosive sublimate; 
Riverius caustics; Pouteau the actual cautery. But Mr. Good, (vol. 
ii. p. 290,) justly observes that radical success must, after all, depend 
upon supporting and giving strength to the system by cordials and 
tonics, for if this cannot be accomplished, it is perfectly clear 
that the predisposition will be neither subdued nor subside spon- 
taneously; that the ulcerations will not heal, and the system must 
gradually sink under their constant discharge and irritation." 
I should have added that in case of sphacelus actually taking 
place, the carrot poultice, or the poultice of carbon, or the ferment- 
ing yeast poultice may be applied to correct the fcetor and to re- 
new a healthy action in the parts affected. 



446 



LECTURE XXXVII 



PHRENITIS, OR INFLAMMATION OF THE BRAIN. 



The term Phrenitis is derived from- the Greek word $wv, the 
mind, supposed to be seated in the brain. Dr. Cullen gives the 
following definition of this disease : " Pyrexia vehemens; dolor 
capitis; rubor faciei et oculorum; lucisetsoni intolerantia; |fervi- 
gilium: delirium ferox vel typhomania:" meaning by this last term, 
what the Greeks usually associated with it, a degree of coma, or 
heavy stupor, with delirium, lethargy, and madness. These are 
the characteristic symptoms. Dr. Cullen acknowledges that he 
added typhomania to his definition, to designate the coma attendant 
upon that form of the disease, which appears to reside in the brain 
itself, as distinct from the membranes ; but he adds that, upon 
further reflection, he finds no foundation for this ; and that the 
symptoms he has included, always mark the acute inflammation, 
i. e. of the membranes; while the other of the parenchymatous 
exhibits a more chronic affection. This chronic character is his 
only mark of the latter form of the disease, without pointing out 
its' insidious character. Dr. Cullen divides phrenitis into 
idiopathic and symptomatic. At the first view of the symp- 
toms already related, we should be inclined to consider it 
always symptomatic of fevers of great excitement, in which 
we generally observe more or less of affection of the brain and 
nervous system. It is symptomatic also of typhus, worms, erup- 
tions, as erysipelas, hydrophobia, injuries of the brain, and strong 
passions, particularly severe grief. But dissection has shown it to be 
an idiopathic as well as a symptomatic disease, and that although 
attended with general symptoms of synocha, it is still a true idio- 



PHRENITIS- 447 

pathic inflammation of the brain or its membranes. Sauvages, 
Linneus, and Sagar divide it into inflammation of the brain and 
its membranes; i. e. into phrenitis, denoting the inflammation to 
be seated in the membranes, and cephalitis or sphacelismus, as 
seated in the larger vessels, or in the substance of the brain itself. 
This distinction, you will perceive, I have adopted for the reason 
that it furnishes an important practical distinction in the sick 
room. Dr. Cullen says that he admits the full force of the dis- 
tinction between inflammation seated in the membranous parts, 
and that which is seated in the parenchyma of the viscera, (yet in 
his Nosology, as you have seen, he can pronounce all such distinc- 
tions visionary;) but he considers it very difficult to make such 
distinction in the present case of inflammation of the brain. Wil- 
lis, Langrish, Huxham and Pringle have all related cases of ab- 
scesses being actually formed in the substance of the brain, when 
the symptoms of inflammation have been inconsiderable, or not at 
all to be observed ; therefore such inflammation must have pre- 
viously existed in the brain, but not in the membranes, and con- 
sequently should have been designated by Dr. Cullen ; indeed 
Dr. Baillie (see Morb. Anat. ch. 25.) observes, that the most usual 
termination of inflammation of the substance of the brain is in ab- 
scess. Dr. Fordyce has observed that when seated in the mem- 
branes the pain is acute ; but when seated in the substance of the 
brain that it is obtuse and less sensble ; so in hydrocephalus, the 
pain is at first not acute, yet certainly, judging from the effects, 
inflammation exists previously to the effusion of water. Dr. Parr 
remarks, if in any part of the body, this distinction between mem- 
branous and parenchymatous inflammation be called for, it is in 
inflammation of the brain. We may observe that when inflamma- 
tion is seated in the brain itself, all the symptoms of inflammation 
are comparatively mild ; i. e. almost all the symptoms of mem- 
branous inflammation of the brain are present, but that they exist 
in an inferior degree ; see my Nosology — read the distinction of 
species. Dr. Good, I perceive, has adopted the same distinction. 
Cephalitis comes on with a slight head-ache, increased heat of the 
head, a disinclination to motion or business ; if a child, it is gene- 
rally found reclining its head upon its mother's lap, upon a chair, 
or against some substance near which it may be sitting ; the pulse 
in the first instance is quickened, but it is comparatively full ; at 
least, it is not corded as in membranous inflammation; but as the 



448 LECTURE XXXVII. 

disease advances, the pulse becomes more slow, and more full, 
attended with coma. The pain too is deep seated, and considera- 
ble stupor follows, occasionally interrupted with sharp shooting 
pains ; the pain, however, is not constant. Cephalitis ending in 
hydrocephalus, generally attacks those of irritable and nervous 
temperaments ; not so much the full habit ; hence it has been ge- 
nerally remarked, that feeble and sickly children are most usually 
the subjects of it ; and hence too the erroneous and absurd infer- 
ence, that dropsy of the brain is a disease of debility, and the still 
more absurd negative practice arising from this error, instead of 
the antiphlogistic treatment, which alone can snatch the little pa- 
tient from the danger that awaits it. To Dr. Rush again we are 
indebted for a correct view of the pathology of this disease, and 
for pointing out its inflammatory character. Dr. Cheyne, who 
wrote in 180S, also is entitled to much credit for inculcating the 
same doctrine in Great Britain. The disease now is even deno- 
minated, in consequence of this association, phrenitis infantum, or 
phrenitis hydrocephalica. (See an early description of this disease 
by Wm. Paisley, Ed. Ess. vol. iii. by Dr. Whytt, in 1768.) The 
symptoms, as they affect the head, are more like those of conges- 
tion in the last stage of fever, or as in apoplexy. Cases of this 
sort occurred in two young ladies whom I attended, one of this 
city, and the other of Baltimore. They had all the characteristic 
symptoms of hydrocephalus internus; while labouring under this 
disease, they frequently awoke in the night with very acute dis- 
tress in the head. " Oh, my head ! oh, my head V- was their 
frequent cry, and then again they would collapse into the stupor at- 
tendant on such congestion. But besides the quickened circulation 
and the distress it created in the brain, this disease is indicated 
by the white furred tongue, the dry skin, great heat of head, ful- 
ness of its vessels, high coloured urine, a costive state of the belly, 
the loaded and heavy eye ; in the first stage, the preternaturally 
contracted pupil, frequently too expressing the distress of the head 
by habits of frowning, and in the more advanced stage of the dis- 
ease, squinting, or the turned up eye; both the effect of an irregular 
action of the external muscles of the eye. These are pathogno- 
monic of this disease. But as the disease advances, the pupil 
dilates in proportion to the congestion that is produced; in a word 
all the symptoms of inflammation of the membranes are to be 
discerned, but in an inferior degree. 



PHRENITIS. 449 

But the symptoms of phrenitis where located in the mem- 
branes are generally considered as most important to be known. 
I think otherwise, for those which attend upon membranous in- 
flammation cannot be mistaken, while those of the inflammation 
seated in the parenchyma, and which constitute the first stage of 
hydrocephalus, are generally very obscure, compared with those 
of the membranous inflammation, and are accordingly apt to be 
overlooked not only by the family and friends, but also by the 
physician. But in many instances, it is to be observed, that the 
inflammation is not exclusively confined to the membranes, or to 
the substance of the brain, but that both partake in whichsoever 
of the two the disease may have commenced. On this account, 
probably, Dr. Cullen was led to the remark that these two species 
are not to be distinguished, and hence has given no species or 
division of his genus, but even includes many of the genera of 
Sauvages, Linnaeus, and Sagar, under one head. In membranous 
inflammation the pain of the head is very acute and unceasing, at- 
tended with shooting from one part of the brain to the other, and 
occasionally with corresponding transient flashes of light affecting 
the optic nerves and retina; these are attended too with a throb- 
bing of the carotid and temporal arteries. Sometimes the pain is 
most severe in the forehead, at other times in the occiput, but 
more frequently on the top of the head, with a sense of burning, 
conveying the sensation of burning coals on the top of the head, 
or, as the patient expresses it, he feels as if his very brain were 
on fire. The pain frequently too extends to the very surface of 
the scalp. At this we are not surprised, after seeing the com- 
munication of inflammation to the brain from the surface in 
erysipelas. Case of Dr. Bayley's patient on board ship, in which 
the soreness of the scalp pointed out the seat of injury in the 
brain, and led to the successful use of the trephine. The eyes 
also denote the great irritation which exists. They are inflamed; 
the vessels of the tunica adnata are loaded as in idiopathic oph- 
thalmia; the eyes are also painful, and very sensible to light; 
frequently too, flashes of light pass across them ; they exhibit 
fierceness of look, which is very manifest to the ordinary obser- 
ver. In some a wild acute stare, and a remarkable quickness in 
the motion of the eyes are very characteristic of the impulse that 
is within. The hearing too is affected ; at first it is quickened, 
but afterwards deafness ensues. This, however, takes place, 
39 



450 LECTURE XXXVII. 

most commonly, at the close of the disease, and is the attendant 
upon the form which is among the consequences of the preceding 
excitement or inflammation, and of the effusion which follows it. 
The countenance is flushed, not only pointing out the general ex- 
citement of the system, but evidently marking an extraordinary 
impetus in the vessels of the brain, and a great determination to 
the head. The manner of the patient also shows great agitation 
of the whole nervous system; he is hurried, agitated, anxious, 
impetuous; both mind and body partake of the irritation. The 
pulse too is frequently hurried like the whole system, hard cord- 
ed or incompressible. Respiration corresponds with the circula- 
tion ; it is also quickened, and as is to be expected when the ner- 
vous system is violently invaded, it is anxious, analogous to what 
we see in the yellow fever; indeed there is some resemblance in 
the operation upon the brain and nervous system in these two 
diseases. There is also more or less too of irritation about the 
prascordia, showing itself in frequent sighing. The skin is hot 
and dry, and about the face and neck particularly flushed: (not so 
in inflammations in other parts of the body.) The tongue is fur- 
red and covered with a white paste, attended with great and inor- 
dinate thirst. The urine is high coloured, almost bloody, but in 
the advanced stage of the disease it is sensibly diminished in 
quantity, that is, when the current of fluids becomes great to the 
brain, analogous to the scarcity of urine in dropsy : when it be- 
comes dark coloured in the last stage, it is considered by Dr. 
Lobb, (see his Practice of Physic, &c.,) as an unfavourable symp- 
tom, being, as he expresses it, partly hemorrhagic; that is, the 
thinner or serous parts of the blood are chiefly directed to the 
part diseased. The bowels are costive; the secretion of bile is, 
in some cases, increased in the beginning, and is attended with 
bilious vomitings, hence has arisen the mistake of some physi- 
cians, confounding phrenitis and yellow fever, forsooth because 
the stomach is a good deal affected as symptomatic of nervous 
irritation. 

As phrenitis advances in its progress the flow of blood deter- 
mining to the brain increasing, the secretion of bile is dimi- 
nished. The fceces lose the yellow colour ; they become white ; 
this too, according to Dr. Lobb, is a fatal symptom in this dis- 
ease, the pathology of which is, that it denotes a very inordinate 
determination to the brain, and hence a diminished circulation to 



PHRENITIS. 451 

the liver. The brain and nerves continue, as the disease ad- 
vances, to manifest a still more unfavourable train of symptoms. 
Delirium in two or three days shows itself; the first evidence of 
it is incoherence in conversation, and a false imagination. He 
supposes his friends, and those immediately about his person, to 
be his greatest enemies, and constantly meditating evil against 
him. He becomes jealous of every thing passing. He becomes 
very irascible, is easily excited into violent passion, even at his 
favourite connexions and servants, resisting the directions that 
may be given. He is, for the most part, unable to sleep, and 
when he for the moment may forget himself, dreams of a very 
distressing nature agitate him, but he has no recollection of them 
when awake; he is totally unconscious of what has passed; and 
when awake he is alive to every impression; such is his suscep- 
tibility, that even a whisper takes his attention. In a case related 
by Dr. Good, a similar sensibility in the organs of vision and 
hearing took place : " insomuch," says he, " that the slightest 
light and sound, even the humming of a fly, were insupportable." 
(Vol. iii. p. 329.) True delirium ferox follows. He picks at 
the bed-clothes, catches at flies; the muscse volitantes are be- 
fore him; he gets out of bed, manifests great strength and even 
violence; he requires force to confine him; he swallows his 
food and drinks with great hurry, and that with a convulsive 
effort, and sometimes hiccups, for the nerves of the diaphragm 
participate in the disease; in a word, it becomes perfect mania of 
the acute sort. Stoll relates an extraordinary instance of the 
chronic inflammation of the brain that ended in mania, but not 
till it had been of nine weeks continuance. Rat. Med. sect. iii. 
p. 175. Delirium is one of the characteristics of this inflamma- 
tion, though not of the phlegmasia^ in general, except synochal 
fever. In the phlegmasise the general excitement too, is fre- 
quently as great as in a general fever without local inflammation, 
yet frequently no delirium takes place ; but in this disease, phre- 
nitis, delirium appears among its earliest symptoms, not only be- 
cause the disease is seated in parts, which inflamed, possess great 
sensibility, but particularly because it at the same time involves 
the seat and source of all excitement, the brain itself, to which 
the inflammation usually extends; whereas, in the other phleg- 
masia, seated in other distant parts of the body, the excitement of 
the brain is taken off; the current has a different direction, with 



452 LECTURE XXXVII. 

the exception of ophthalmia, and that variety of erysipelas we 
have noticed called sideratio, and as we shall find also to be the 
case in obstruction of the lungs as in paripneumony. In those 
cases delirium is induced and easily accounted for : in the two 
former by a direct flow of blood to the brain, and in peripneu- 
mony by the resistance which such injection of the lungs makes 
to the circulation through the chest, and thereby to the return- 
ing blood from the brain. I might have added another of the 
phlegmasia?, in which delirium is a common attendant symptom; 
diaphragmitis, in which this disturbance of the brain proceeds 
from the irritations of the important nerves distributed upon that 
muscle. Such are the symptoms from the third to the sixth or 
seventh days of the disease. A different train now succeeds, de- 
noting the termination of the inflammation, either by coma, the 
effect of effusion in the brain from the inflamed vessels, or we see 
a livid countenance, with coldness of extremities, involuntary 
discharges of the foeces and urine. In some instances this sur- 
charged and excited state of the vascular system is followed by 
hemorrhages from different parts of the body, as from the nose, 
mouth, stomach, bowels, kidneys, attended with some symptoms 
of a general typhoid state of body, but these are of short duration 
when compared with the preceding excitement. 

The following are among the unfavourable symptoms which 
now succeed, and which indicate a fatal result : 

1. Coma with deafness. 2. Grinding the teeth. 3. Hiccup. 
4. An irregular pulse and small. 5. The stools becoming white, 
or clay coloured, or 6. Hemorrhages from the bowels, colouring 
the stools. 7. Dark coloured urine, or urine mixed and coloured. 

8. Retention of urine from the loss of sensibility in the bladder. 

9. Cold sweats and coldness of the extremities. 10. The invol- 
untary discharge of the foeces and urine. 11. Convulsions; 
these occurring at an advanced period of the disease, are invaria- 
bly fatal. But to aid. you in your prognosis, let me also recount 
some of the symptoms which announce a favourable termination 
of this formidable disease. 1. Early hemorrhage, especially from 
the nose. 2. Spontaneous and copious sweating, or sweating 
easily induced. 3. Diarrhoea in the first stage of the disease. 
4. A plentiful flow of urine. 5. The pulse losing its corded cha- 
racter, becoming full and soft. 6. Disposition to natural sleep, 
not comatose or attended with dreams, and the remembrance of 



PHRENITIS. 453 

his dreams, if he has any, but it is preferable he should have 
none. When the disease may have ended fatally, upon exami- 
ning the brain after death, the effects of the inflammation are 
manifested in some instances by the effusion of blood that has 
been extravasated. In some cases the vessels and sinuses of the 
dura mater are all loaded and distended with blood, while in other 
cases where the brain itself is the original seat of the disease, or 
subsequently involved, we see the effusion of pus. If the inflam- 
mation be located exclusively in the membranes, an adhesion is 
oftentimes found of the dura mater to the skull, and the mem- 
branes themselves thickened. (See Boerhaave and Van Svvieten, 
Aph. 775.) In some cases the dura mater is covered with a gela- 
tinous matter, an additional membrane; in some few cases it has 
been known to end in gangrene. Sometimes too, ossification has 
been found in some of the membranes, even of the pia mater, 
the effect of the plethora and inflammatory action, as in the cases 
of the deposit of earthy matter in the kidney, which I have 
before related. The vessels, as I remarked, are not only all 
loaded with blood, but the ventricles also are frequently found 
distended with serum constituting hydrocephalus interims; and 
in some cases the serum is found diffused between the mem- 
branes as well as within the ventricles, so that we find both 
forms of hydrocephalus, the externus, as well as that within 
the ventricles. But how shall we distinguish phrenitis from 
those diseases which we have enumerated, to which it bears 
a close resemblance ? How shall we distinguish it from mania 
— from synocha — from typhus ? From acute mania it is not 
distinguishable; on the contrary, it is identified with it; I mean 
where mania proceeds from bodily causes, as intemperance, 
fever, violence, &c. From chronic mania it is easily separated; 
this stage of madness being without fever. From synocha, 
phrenitis differs in the pulse. In phrenitis the pulse is more 
corded — in synocha less so — in phrenitis the stomach is more 
disturbed — less in synocha — the organs of sense are less affected 
in synocha, as the sight and hearing — the delirium is much more 
violent, and comes on earlier than in synocha — the faculties of 
the mind are less impaired in synocha — the head being relieved 
in phrenitis, the disease is soon ended — but in synocha the fever 
frequently continues — the duration of phrenitis is usually con- 
fined to six or seven days, and when fatal it proves so generally 
39* 



455 LECTURE XXXVII. 

in that time. Whereas, synocha, says Eller, is frequently of 
longer duration, and then ends in typhus. Between phrenitis 
and typhus the diagnostics are, 1. That the typhoid symptoms of 
phrenitis are of short duration, and compared with the preceding 
excitement, are relatively mild. It exhibits less vitiation too, of 
the general state of the system. 2. In phrenitis the hemorrha- 
ges are more violent, and they are the chief evidence of a broken 
up state of the system, the effect of violent action; the fluids being 
less affected, as it regards their quality, than they are in a pro- 
tracted synocha or typhus. 3. The eyes, too, differ; in phrenitis 
they are inflamed and sparkling; but in typhus they are also 
loaded with blood, but they are glassy and dull. 

CAUSES. 

The predisposing causes of phrenitis, are, first: 

1. Temperament, especially the sanguine and choleric. 

2. Plethora — hence those who indulge in spirituous and fer- 
mented liquors, not unfrequently become the subjects of this dis- 
ease. Hence, too, young persons are the subjects of this disease; 
and if we include hydrocephalus, we may also say that in child- 
hood there is a strong predisposition to such inflammatory dis- 
eases; for at that early period of life, say from the second to the 
fourteenth year, a much greater proportion of blood circu- 
lates upon the brain, for which reason it is that hydrocephalus 
is the effect of other febrile diseases. Indeed Dr. Gregory of 
London, considers it as so identified with the febrile diseases of 
children, that he even says it is usually known by the name of 
the " infantile remittent fever." 

3. Having once had the disease, the brain becomes afterwards 
liable to returns of it, as we see to apoplexy and mania; even so 
of hydrocephalus. (See Van Swieten.) 

4. A hot climate, and the hot seasons of temperate climates — 
hence coup de soleil, or stroke of the sun, which is inflammation 
of the brain ; but in temperate climates phrenitis is compartively 
a rare disease, except as symptomatic of fever. 

The exciting causes are 

1. Mechanical violence, as a blow on the head. I have known 
a case of an Irish woman, who, throwing a pail of water out of 
the window, threw herself along with it — phrenitis was the con- 
sequence. 



PHRENITIS. 455 

2. The sudden suppression of accustomed discharges, as the 
sudden suppression of milk, of the menses, or of accustomed 
hemorrhoidal discharges, is in some cases the cause of phrenitis. 
Suppression of eruptive diseases, the plethora in like manner 
of gout, sudden check of the lochia has induced the mania — the 
plethora of pregnancy: and especially the circulation called into 
increased action by the irritation of parturition, has thus induced 
phrenitis, as well as the more common effect upon the brain, con- 
vulsions. In some in pregnancy the mind is peculiarly affected; 
the moral principle disturbed, showing a propensity to swear, to 
steal, in those too, who are very abhorrent at those things in a 
perfectly healthy state of body. 

3d. Excessive exercise of body, especially in a hot climate, 
and in the hot seasons of temperate climates. 

4th. The heat of the sun — coup de soliel ; easily renewed, 
and frequently assumes the general symptoms of synocha, or the 
fever with which phrenitis has frequently been confounded by 
some of our physicians. 

5th. Spirituous liquors are a prolific parent of this disease. 
Most of the cases of acute mania in our asylum, are, I believe, 
occasioned by this cause. 

6th. An exciting cause is excessive exercise of the mind, either 
intense application alone, or intense thought, with great anxiety 
of mind, or the indulgence of strong passions. Love, and reli- 
gious fanaticism have, in this way, been the cause of phrenitis 
or acute mania. Intense application of the mind to business, and 
anxiety, induced this disease in the late Mr. Cheetham. 

7th. Want of sleep is also an exciting cause of phrenitis. In 
other words, this may resolve itself into the former; i. e. ex- 
cessive exercise of mind, the effect of watchfulness. 

Sth. Excessive venery has produced this disease. 

9th. Poisons; viz. copper, mercury, and arsenic. 

Case of phrenitis, induced by eating fish, caught on the copper 
banks. Dr. Bayley. Cases of hydrocephalus from mercury — - 
and learn a caution as to the repeated use of this metal for sup- 
posed worms, or in fevers in young children, lest you create this 
most formidable and fatal of all the diseases. (See Bedingfield 
on hydrocephalus internus: p. 27.) In the first stage of this dis- 
ease, I apprehend that mercury is very injurious — that it only 
serves to increase the febrile symptoms. (See also, p. 16, 21.) — 



4 56 LECTURE XXXVII. 

read Blackall too, on dropsies — Parry also. Such are the sources 
of idiopathic phrenitis. Symptomatic phrenitis is most generally 
the effect of synocha; infantile remittents ; pestis; yellow fever, 
or typhus in its various forms. But in some cases, it is the at- 
tendant of smallpox, measles, and other inflammatory diseases — 
then the effect of suppressed eruption. In some cases, it is the 
attendant upon the first stage of fevers ; in others, it supervenes 
upon the last stage of febrile diseases, and is the effect of local 
congestions. Phrenitis being a symptomatic, as well as an idio- 
pathic disease, we hence can readily account for the epidemic 
phrenitis which has been described by Saalman, in the 32d vol. 
of the Leipsic Trans, called " Acta Erudita." In some cases, he 
states the phrenitis he describes to be intermittent, either return- 
ing daily, or every second day. The blood drawn in it, too, he 
observes, has not always the buffy coat; (but which is to be ex- 
pected in most continued fevers.) Bedingfield made the same 
observation. The delirium, too, in his phrenitis does not come 
on until the fifth, sixth, or seventh clays. A very accommodat- 
ing species of phrenitis truly — almost as much so as Beglivy's 
yellow fever, noticed by Dr. Miller, in which it was not 
proper to give a purge till the seventh day. Saalman also re- 
marks, that the epidemic phrenitis he describes frequentty 
terminated in pneumonia. It therefore surely must have been 
general fever, but not phrenitis. He observes, too, that it attacked 
the old as well as the young; and that it was most fatal to those 
above forty years of age; and that the hypochondriac and melan- 
cholic temperaments were most subject to it. That they should 
readily take fevers to which their fears alone would predispose 
them, is not improbable; but that they should be most liable to 
attacks of phrenitis is indeed most extraordinary, and is contra- 
dicted by all experience. The treatment of idiopathic phrenitis 
demands our chief attention; but we may remark of symptom- 
atic inflammation of the brain, that our remedies should always 
be prescribed with great caution, paying due regard to the pecu- 
liar cause; the character of the fever indicating it, and the stage 
of the disease, as well as the habit and strength of the patient. 
In the first stage of the disease, if it be synocha, yellow fever, or 
typhus, as we have already remarked, the use of venesection, 
active purges, or bisters is indicated; but in the last stage, a 
more cautious, and, sometimes, a very contrary treatment may be 



PHRENITIS. 457 

called for. In the treatment of idiopathic phrenitis, general vene- 
section, repeated even to syncope, says McBride, is a good prac- 
tice — until a state resembling apparent death, says Dawson, (p. 
71.) No regard should be paid to the quantity drawn. An abate- 
ment in the violence of the affection of the brain should alone 
determine the frequency of bloodletting, or the quantity drawn. 
Indeed, I would remark, that bloodletting oftentimes fails in the 
removal of active inflammatory diseases, by the common practice 
of physicians, directing the limited number of ounces to be 
drawn, instead of urging it to be continued and repeated until a 
mitigation of the disease is perceptible. Twenty or thirty ounces 
drawn in the forming, or early stage of phrenitis, will do more 
than three times that quantity drawn at different times. In these 
inflammatory diseases, too, the patient bears the loss of blood 
without the same deliquium or sense of exhaustion that he would 
experience under other circumstances. The man who in health 
would faint at the loss of a pint of blood, under the excitement 
produced by phrenitis or gastritis, enteritis, or other inflamma- 
tory disease, seated in sensible parts of the body, will bear the 
loss of two or three pounds without the least inconvenience; and 
at the moment of drawing it will perhaps not exhibit the least 
evidence of the change and depression which will in a short time 
be perceived from it. Venesection, too, in the foot may per- 
haps be more useful than from the arm, upon the principle of re- 
vulsion. Burserius is favourable to this principle. (See also Med. 
Recorder: paper on blood-letting, by Dr. Ducachet: vol. iii. p. 
461: also vol. v. p. 1S7.) Local blood-letting by leeches, cupping, 
division of the temporal artery. Opening of the jugular vein is 
recommended by Hoffman, Cullen, Ellis, Dawson. These last 
are unnecessary, and sometimes attended with difficulty, and in- 
deed danger in delirium. They are also improper on account 
of the tight bandaging of the head and neck, to close the divided 
arteries and veins. 

Purging. — Saline purges are preferable; or, calomel and jalap. 
These should be frequently repeated. It is also usual with most 
writers to advise blisters to the head, which should be inva- 
riably shaved; but, query, would it not be preferable to apply 
them successively to the wrists and ankles — to the arms and 
thighs? And do not blisters, applied to the head, like the in- 
flammation of erysipelas, rather invite an increased quantity 



458 



LECTURE XXXVII. 



of blood to the brain, as well as to the outside of the head? 
I am of this opinion, and am confirmed in it by the so com- 
mon failure of them in hydrocephalus. Diaphoretics, antimony 
and crem. tart., or antimony and calomel blended; or sp. mind, 
and laud. Camphor is very generally recommended by prac- 
tical writers, as beneficial in this disease of excitement; and, 
by the by, this is an indirect evidence that it is not the powerful 
stimulant that it is represented; and if this medicine be proper 
in phrenitis, it is assuredly a poison in the typhoid state of fever, 
in which also it has been recommended. If perspiration be de- 
sirable in phrenitis, encourage the use of the diaphoretics by tepid 
drinks. For the same reason, too, the warm bath and the pedi- 
luvium are indicated, to aid in relaxing the surface. And for the 
same reason, cold applications to the head, cold water, cold vine- 
gar and water, cloths wet with sether, the spirituous applications 
recommended by Mr. Bedingfield, (see his Compendium, p. 37, 
first, ed. ) and the clay cap recommended by most practitioners, 
Cullen, and Thomas, and Good among the rest, should be totally 
prohibited. Perspiration, with the aid of blisters, will do infi- 
nitely more good in diminishing the determination to the brain; 
and if the irritation of blisters, or the discharge by perspiration, 
be useful in lessening the excitement within, how is it possible 
that cold affusions can be proper or justified upon any principle 
whatever? On the contrary, do they not, by diminishing the 
quantity of blood in the external vessels, increase the fulness of 
those within? And do they not, by diminishing perspiration, add 
to the fulness of the vessels of the brain? They did so in the 
very case related by Good, (p. 330.) He had nearly lost his pa- 
tient, but he was saved by Dover's powder and diaphoresis. (Ibid,) 
Diuretics are also useful medicines in this disease; i. e. such as 
do not operate by exciting the system. The nitrate of potash 
is among the best of this class of medicines: gr. x. or gr. xv- 
may be given every two or three hours in drink, or in com- 
bination with the diaphoretic medicine with advantage, in this 
disease. Digitalis may also be prescribed with advantage in phre- 
nitis. If it ever be useful, it will be so in this case. But it is not 
to take the place of any of the remedies that have been mention- 
ed. It may be employed as an auxiliary, but is not to be trusted 
alone. Belladonna, stramonium, hyosciamus, have been used by 
Baron Storck and others. When this disease, as is sometimes the 



PHRENITIS. 459 

case, proceeds from suppressed menses, we are told always to 
attend to this habitual discharge, and to see that the menses are 
restored. This is not always practicable, and indeed it is unim- 
portant, if other vicarious evacuations be substituted; for we 
know that the state of that function is intimately connected 
with the general plethora of the system, and not on local ful- 
ness, or congestion alone, as contended for by some writers. 

Diet. — Bread and water, or at most, sago, arrow-root, gruel, or 
barley-water. Sub-acid drinks: crem. tart, and tamarinds. 

Regimen. — The position of the head and shoulders should be 
elevated, for the purpose of diminishing the flow of blood to the 
brain — this is essentially important. Avoid light, heat, noise, 
business, conversation. Have as few attendants as possible; none 
but those neeessary for the purpose of administering to the pa- 
tient should be present — more disturb him. In a word, let the 
most rigid antiphlogistic, or sedative treatment be in every re- 
spect strictly pursued, as it regards medicine, diet, and regimen. 
And when the patient has become convalescent from this inva- 
sion of the brain, remember that inflammation may be easily re- 
newed in this organ, the seat and source of all sensation. Let 
him, therefore, return very cautiously to his accustomed diet, and 
particularly to the use of animal food, wine, and other stimuli, 
composing his diet in a state of health. And let him still more 
cautiously return to his ordinary pursuits, especially if of a pro- 
fessional sort, as they in a particular manner occupy the mind. 



460 



LECTURE XXXVIII. 



OPHTHALMIA. 



The eye is at all times an organ of exquisite sensibility to im- 
pressions, but when it becomes the seat of inflammation the suf- 
ferings connected with it are peculiarly severe and dangerous, 
not only to the organ itself, but so numerous are its nerves, and 
so immediately connected with other important senses, and with 
the brain itself, that such inflammation is frequently transferred 
even to the brain, and thence involves the whole system in dis- 
ease. In this manner I have seen ophthalmia a fatal disease. It 
is at all times important, and calls for active treatment on the part 
of the physician. Recollect that the eye has several pairs of 
nerves bestowed upon it, besides several branches of other pairs 
not immediately belonging to it. 

1. The optic. 2. The ophthalmic branch of the fifth pair, the 
trigemini, and which holds extensive connections by means of its 
other two branches, the superior and inferior maxillary. 3. The 
motores oculorum, which are distributed upon the straight muscles 
of the eye. 4. The trochleatores, or pathetici, which are spread 
upon the oblique muscles. 5. The abductores, or abducentes, the 
sixth pair of nerves proceeding to the abductor muscles ; and 6. 
A branch of the seventh pair, auditory, that is, coming from 
the portio dura of that pair. Seeing then that the eye holds such 
extensive communications, we are taught the importance of active 
treatment whenever it becomes the seat of inflammation, for such 
is the determination to parts thus highly organised that they 
readily become overwhelmed. The characteristic symptoms of 
ophthalmia, according to the definition given of it by Dr. Cullen, 



OPHTHALMIA. 461 

are great redness and pain ; intolerance of light ; attended for the 
most part with an increased flow of tears. (Rubor et dolor; lucis 
intolerantia ; plerumque cum lacrymatione.) Dr. Culien divides 
it first into idiopathic and symptomatic ophthalmia. The idio- 
pathic he again subdivides into the opthalmia membranarum, that 
is, as seated in the adnata and its subjacent membranes, and the 
ophthalmia tarsi, or the inflammation seated in the lids, more 
especially in the sebaceous glands, or glandulae meibomU 
which beset them. These when inflamed are swelled, followed 
by more or less erosion and a glutinous exudation, which occa- 
sions them readily to adhere after being kept in contact, as is the 
case in sleep. But you cannot readily have one of these parts 
inflamed without the other, that is, when seated originally in the 
membranes; the tarsus is, in that case, soon involved, and vice 
versa, the tarsus being the primary seat of the disease the inflam- 
mation is soon extended to its membranes. Mr. Ware, indeed, 
who has seen more ophthalmia than almost any other man living, 
expresses the opinion that the greater part of the cases of ophthal- 
mia which occur, originate in the lids, and from thence com- 
municate to the eye itself; and that very few cases occur that 
spontaneously originate in the membranes. The symptomatic 
inflammation of the eye, Dr. Culien also divides under two heads, 
1st. As symptomatic of some other disease of the eye itself, as 
trichiasis, or entropium, that is, the hairs of the lids turned in 
upon the eyes. 2d. As symptomatic of diseases of other parts of 
the body, or of the whole system, as, scrofula, syphilis, measles, 
scarlatina, fever, or phrenitis. When the disease is seated in the 
membranes, or eye-lids, the whole eye soon manifests the pre- 
sence of an unusual flow of blood to the part; small serous vessels 
now carry red blood that before were not at all or scarcely per- 
ceptible, In some instances, the eye becomes blood-shot by the 
effusion of blood from some of the vessels that may have been 
ruptured by the new determination that takes place. The patient 
at first has the sensation of some foreign body in the eye, and is 
not easily convinced that this is not really the case, arising 
merely from the turgescence of its vessels. This sensation is 
soon succeeded by acute pain, and frequent flashes of light pass- 
ing before the eye; a great flow of tears now takes place; these 
too are not only increased in quantity from the whole surface of 
the eye, and from the lachrymal glands, but the discharge itself is 
40 



462 LECTURE XXXVIII 

changed in its qualities, and is rendered very acrid. They are in 
such quantity that they pass over the lids, and in some instances? 
scald the cheek as they flow, producing even an erysipelatous in- 
flammation of the face; and those which pass by the natural chan- 
nel into the nostrils inflame that passage also, and in connection 
with the inflammation extending from the eye, have induced 
fistula lachrymalis by the inflammation induced in the ductus ad 
nasum; but the inflammation not only changes the secretion from 
the surface of the eye and that of the lachrymal gland, but the 
secretion of the eye-lids is also affected by it; the secretion by the 
nose also partakes of it. These organs, indeed, mutually act one 
on the other. If originally seated in the lids, as Mr. Ware ob- 
serves, the membranes become affected, and if in the membranes, 
the lids, in their turn, frequently show it. Hence it happens, that 
we see the lids adhering in most cases of ophthalmia, whether ori- 
ginating in the lids or in the membranes. But the inflammatory 
action of this disease is not confined to the eye itself, the whole 
system frequently manifests it by the general febrile symptoms 
attending it, and which are those of synocha, showing itself in the 
circulation, respiration, the various secretions, and excretions, and, 
indeed, more or less in all the functions of the system; for the most 
part, however, such is the determination to the head, that the pa- 
tient complains much of headache as well as pain of the eye, great 
sensibility to the light, throbbing of the carotid and temporal ar- 
teries, and of flashes of light frequently passing through the eye ? 
as in phrenitis. In some instances, as already intimated, the 
brain itself becomes the seat of inflammation, and renders it a 
fatal disease. 

Ophthalmia has various terminations : in some instances, as in 
other inflammations of secreting surfaces, it is removed, 1st. by 
resolution; or, 2d. it ends in an increased secretion, and by pu- 
rulent secretion from the external surface; and when such dis- 
charge takes place externally, it affords relief analogous to the re- 
lief afforded by purulent discharges from other inflamed surfaces, 
as the nose, throat, or surface of the lungs; and, indeed, this is 
another example of a purulent secretion, without actual ulceration 
or destruction of parts but from a mere change in the state of 
the exhaling vessels, as in gonorrhoea, phthisis, &c. &c. 3dly. 
In other cases ophthalmia terminates by an effusion of pus inter- 
nally, behind the cornea, constituting hypopion, (so called from 



OPHTHALMIA. 463 

v*oj, under, and jtvov, pus,) or in a less degree, in which a very 
partial or inconsiderable discharge takes place behind the cornea, 
when it is called, from a resemblance to the circle on the nail, 
onyx, from owl, a nail. 4th. Inflammation of the eye in some 
cases ends in a thickening of the membranes, the seat of the dis- 
ease; the whole scelerotic coat becomes thickened; in other in- 
stances the cornea is rendered opaque, and is totally lost in the 
general disease of the eye; and as ossification was found in phre- 
nitis, so in ophthalmia it has been known to be attended with an 
ossification of the coats of the eye, and indeed may have had some 
agency as a cause of the inflammation. 5th. Ophthalmia in some 
cases produces a disease of the crystalline lens, either obstructing 
the lens itself, or the capsule investing it; in either case ealigo, or 
cataract, is the consequence ; inflammation is not always the fore- 
runner of cataract; it is sometimes the effect of congestion from age. 
6th. Inflammation of the eye is, in some instances, succeeded by 
amaurosis, or a paralytic state of the retina, the extension of the op- 
tic nerve upon the posterior part of the eye. (See Trucke'sHistoria 
Ophthalmias ) 7th. Ophthalmia produces a new growth of ves- 
sels upon the adnata constituting membrana, or film. This re- 
ceives the name of pterygium, from Hts^vt^ a wing, bearing some 
resemblance in its shape to a bird's wing. 8th. In other in- 
stances, it ends in a large effusion, within the eye, of water, or 
pus, constituting a dropsy of the eye, producing in either case, a 
great distension and overgrowth of the eye, which occasions it 
to protrude from its socket far beyond the lids, insomuch that the 
lids can no longer cover but a small portion of the tumor thus 
produced. This hernia, or displacement of the eye, is now de- 
nominated staphyloma, from some supposed resemblance to a 
grape. It looks, however, in many cases, much more like a 
blood peach than it does like a grape. In this state of things 
it is not unusual for the action of the muscles compressing the 
eye to produce a rupture of the e)^e itself. 9th. It frequently 
ends in sphacelus and death. These being the consequences 
of inflammation of this important organ, it necessarily calls 
for all your attention ; and let me entreat you, in every case to 
which you may be called when you may enter into practice, to 
keep these terminations before you as a possible event, if you 
should omit the use of those means which are indicated in a dis- 
ease seated in an organ of so much sensibility. 



464 LECTURE XXXVIIL 

CAUSES OF OPHTHALMIA. 
Predisposing — 1. The sanguine temperament. 2. A plethoric 
habit of body, especially kept up by intemperance; sensibility 
induced by — 3. A former attack. 4. Change of climate from a 
cold to a hot one, or from a clouded atmosphere and short days, 
to a clear atmosphere and a long day. These changes induced 
ophthalmia in the British troops in Egypt. 5. Debility and con- 
sequent increased sensibility. The effect of disease predisposes to 
ophthalmia, as after fever and the confinement it produces. In 
like manner women after the confinement of parturition and the 
debility attendant upon it, are liable to this disease. 6. A dis- 
eased state of the constitution, as scrofula or syphilis predisposes 
to ophthalmia. The exciting causes of ophthalmia all resolve 
themselves into irritation applied to the eye itself, as— 1. By 
mechanical injury; a blow and a black eye we know to be very 
generally associated; but the red or inflamed eye usually pre- 
cedes the black. 2. Inversion of the eye-lids or trichiasis. A case 
is related by Dawson, (nosology, p. 57,) in which this disease had 
been of forty years duration — the effects of hairs which were re- 
moved as fast as they reappeared. For the first seven years they 
reappeared — they were conquered at last. 3. Sand or lime is 
a frequent exciting cause of inflammation. The sands of Egypt 
are a productive source of ophthalmia, independently of other 
causes in that climate and country. The sands of America pro- 
duce the same disease as those of Egypt. During Lewis and 
Clarke's travels up the White Earth river, the party were tor- 
mented with sore eyes occasioned by sand which was driven 
from the sand bars in such clouds as often to hide from them the 
view of the opposite bank. The particles of this sand are so fine 
and light that it floats for miles in the air like a column of thick 
smoke, and penetrates every thing. " We were compelled, " says 
the writer, "to eat, drink, and breathe it very copiously." 
(Quarterly Review, 332, January, 1815. Lewis and Clarke's 
Travels to the Missouri.) 4. Chemical stimuli may be enu- 
merated. The nitrous fumes of the soil of Egypt, and especially 
the sharp effluvia after the retreat of the Nile, consequent upon 
its overflow, are of this sort. According to Sonnini and Sir 
Robert Wilson, these are among the most frequent causes of that 
disease: and hence they account for the fact, that in Cairo diseases 



OPHTHALMIA. 465 

of the eyes are almost universal ; blindness and ophthalmia are 
met with at almost every step in that city. 5. Excessive exer- 
cise of the eye, as in looking at minute objects, sitting up late at 
night, and over exertion of the eyes in writing or reading. These 
sensible organs readily become affected, if not by active inflam- 
mation, great weakness is the result. 6. Excessive quantity of 
light suddenly let in upon the eye. The new born infant, is very 
liable to inflammation of the eyes, especially if its attention be 
long and steadily attracted by the fire or a candle immediately 
upon birth, when it has just emerged from its dark abode. In 
like manner ophthalmia is a common consequence of snow when 
of long duration on the ground. 7. The heat of climate. 
8. Cold, by the sudden suppression of the secretions, is a very 
common exciting cause of inflammation, especially in persons 
who have before suffered an attack. 9. The diminished excre- 
tions attendant upon other diseases and sometimes the morbid 
materials of other diseases induce sympathetic ophthalmia, as 
syphilis; not by metastasis, as maintained b}^ Dr. Gregory, of 
London, but by the matter of gonorrhoea directly applied to the 
eye — scrofula, fever, erysipelas, measles, scarletina, catarrh, and 
small pox, and bowel complaints. Cases are related by Dr. 
Why the of Edinburgh, in which ophthalmia invariably followed 
disorders of the stomach and bowels; but these probably, as well 
as ophthalmia, were the effect of a suppressed state of the excre- 
tions by the skin. A tenth exciting cause is contagion. In this 
way inflammation of the eyes by the purulent matter excreted, is 
frequently communicated by contact, as at boarding-schools — in 
regiments of soldiers, and in families, where several persons fre- 
quently wash in the same basin, and wipe upon the same napkin; 
for it is now ascertained that the sphere of the contagion of oph- 
thalmia is limited, and as Mr. Edmonston observes, is chiefly 
ascribed to contact, analogous to the purulent ophthalmy of new 
born infants, which Mr. Gibson of Manchester, and Mr. Ware, 
suppose to be excited by the acrid discharges of the mother, that 
is, in cases of leucorrhcea preceding or attendant upon the birth of 
a child. But is this not always the case ? Other causes may satis- 
factorily account for this effect, as already remarked. By this 
communication between the soldiers in Egypt, it is probable this 
disease was rendered communicable, and in this way conveyed to 
Malta, Gibraltar, and England, as well as, in a few cases, to the 
40* 



466 LECTURE XXXVIII. 

United States. Some of the regiments returned with many sol- 
diers totally deprived of sight. Yet seeing that the matter of 
leucorrhoea and of gonorrhoea applied to the eye produces a simi- 
lar purulent eye, is not the purulent eye of Egypt thus propa- 
gated, and not by a specific material — seeing that such spe- 
cific material is not necessary, as any matter from another dis- 
eased surface will excite inflammation, applied to that tender 
organ the eye ? The contagious character of this disease, as it 
first appeared among the British soldiers, although it may have 
had its origin in that country, has been very generally believed. 
Numerous and decided testimonies, says the London Medical 
Review, (vol. i. p. 15,) leave us not at liberty to doubt that, 
though believed to be peculiar to Egypt, the same disease has 
been imported into England. (See also Welsh's Journal of the 
campaign in Egypt, p. 182. Power's attempt to investigate the 
ophthalmy of Egypt, 1803. Treatise on ophthalmia, Ed. 1806, 
p. 48. Dewar's Inaug. Diss. 1804.) Do not all the facts on the 
contagiousness of ophthalmia, admit of explanation in the manner 
already pointed out ? 



TREATMENT. 

In the treatment of idiopathic ophthalmia, our indication is, to 
remove the remote causes as far as possible. Where it arises 
from a foreign body, as sand, lime, or other substance, it should 
be removed by a probe or by immersing the eye in water. 

2d. To diminish the quantity of blood flowing in the vessels 
of the eye and the neighbouring parts, and to diminish the gene- 
ral and local excitement attendant upon the inflammation of that 
sensible organ, and 

3d. When such inflammation has been subdued, to restore the 
tone of the debilitated vessels, to remove the consequences of the 
preceding inflammation, and thereby to prevent a return of the 
disease. 

The exciting cause being removed as far as practicable, we are 
next to take off the momentum of the vessels of the part inflamed; 
that is, to diminish the volume and the velocity of the blood cir- 
culating upon the diseased part. This is to be done, 

1st. By venesection general and local, by the lancet; it is not 



OPHTHALMIA. 467 

necessary, however, that it should be carried to deliquium, as re- 
commended by Mr. Vetch; yet, copious, large, and repeated 
blood-letting is indispensably necessary. In like manner, cup- 
ping, leeching, and scarification, should be made use of to empty 
the vessels of the parts affected ; not, however, by the rough 
grains of wheat ! ! as recommended by the author of the Edin- 
burgh Practice of Physic; but by the lancet or a delicate knife, 
or the small curved scissors. In the use of scarification, let me 
also advise you to confine it to a division of the congeries of ves- 
sels at the inside of the lower lid, and not as is customary, pass 
your lancet and knife across the membranes of the eye itself. 
This mode of scarification is extremely painful, and adds to the 
irritation instead of diminishing it; but applied to the part men- 
tioned, and the vessels freely divided, or a portion of them cut 
away with the scissors, which is preferable when they are very 
numerous and large, you obtain every advantage that can be de- 
sired, for it empties the vessels of the whole eye, as far as scarifi- 
cation can accomplish it. 

2. Cathartics are an important means of depletion in this dis- 
ease; and for the purpose of exciting large discharges, and at the 
same time diverting irritation from the part affected, they should 
be active; such as the saline cathartics and the active purge, so 
frequently recommended, calomel gr. vi., jalap gr. xv., and the 
super tartrite of potash gr. xv. combined. Kirkland objects to 
the saline cathartics in ophthalmia, particularly, but, I believe, 
without good reason; on the contrary, they are among the best 
purgatives we can employ in this or other inflammations. 

3. Sudorifics, such as have been mentioned in phrenitis, are 
also called for in ophthalmia, viz: sp. mind, and laud., the anti- 
monial solution, small doses of antimonial wine and laudanum, 
or calomel and James' powder, with the addition of a small 
quantity of opium; or Dover's powder. Scarpa's prescription is, 
antim. tart. gr. i.; decocti hordei Ifeiss.; crystal tart. 3i., sacchar. 
3ij. M. You perceive the addition of laudanum or opium in most of 
these diaphoretic medicines, not only because they aid in that 
respect the operation of the medicine with which they are com- 
bined, in relaxing the surface, but for the purpose of diminishing 
the great irritation which inflammation produces when seated in 
parts of so much sensibility : in such cases opium is peculiarly 
useful. The practice indeed of Mr. Ware is to apply the vinous 



468 LECTURE XXXVIII. 

tincture of opium or laudanum itself to the eye, by dropping one or 
two drops into the eye, two or three times a day; he observes 
that, although it occasions a momentary excitement, it produces 
permanent ease to the patient ; and that he has prescribed it with 
great success, after the necessary evacuations have been made 
from the system. As in inflammation of the toes, opium was found 
useful by Dr. Pott ; so it may prove beneficial in diminishing 
ophthalmia. After venesection and purging especially, you need 
not fear its stimulating operation upon the system ; but before 
evacuations have been made, you have great reason to apprehend 
injury from its sedative operation upon the circulating system, 
and especially the smaller vessels, in consequence of which the 
larger are more distended, and thus inflammation ultimately in- 
creased; this you will find a common event of the too early use 
of opium in inflammatory diseases. Mr. Bedingfield also, I find, 
concurs in the use of opium after scarifications ; after the parts 
have ceased to bleed, he recommends that the eye be kept con- 
stantly moistened with a watery solution of opium, from one to 
two grains of the extract dissolved in an ounce of water, to be ap- 
plied cold or warm, as the feelings of the patient may indicate. I 
have no doubt of the benefit of this application. 

4. Blisters behind the ears, to the temples, or between the 
shoulders, are also found useful remedies in diverting the inflam- 
mation from the parts affected. But let me caution you against 
their application immediately over the eyes, as directed by some. 
They are in that case so near the parts affected, that they are 
more likely to increase than diminish the inflammation; but the 
greatest objection is, that a portion of the ointment may find its 
way to the inside of the lids, in which case it must assuredly 
aggravate the disease. 

5. Setons are advised, by many physicians, in ophthalmia, as 
preferable to blisters. In chronic inflammation, a remedy of more 
permanent operation is, perhaps, in many instances, to be pre- 
ferred ; but in a sudden and acute inflammation, you require the 
more active effects of a blister; but in habitual scorbutic or scro- 
fulous affections of the eyes, I prefer the more durable irritation 
of a seton; for, like the disease, setons may be considered as 
chronic remedies, for it indeed requires time for them to produce 
the necessary irritation and discharge. In like manner McBride 
recommends, in habitual ophthalmia, small issues to be made, by 



OPHTHALMIA. 469 

passing a thread of silk or cotton through the lobes of the ears, 
and daily to render them still more active, by means of some 
blistering or other irritating ointment, applied upon the thread at 
the time of moving it. Issues in the arms applied by making an 
incision with the lancet at the insertion of the deltoid muscle, and 
inserting a pea, or by the application of the patent issue plaster, 
are also advised in ophthalmia by many practitioners. I have pre- 
scribed them in chronic cases of that disease certainly with bene- 
fit; but in acute ophthalmia, blisters are to be preferred. 

But, 6th. What applications shall be made to the eye itself, in 
this state of excitement and inflammation ? Many, even in recent 
cases of this sort, advise cold applications; others recommend the 
eye to be frequently bathed with cold water; some direct cold 
poultices of scraped potatoes, or the pulp of rotten apples, to be 
applied to the eye; and most agree in recommending cold lead 
water, and that constantly applied ; but cold applications are in 
my opinion injurious in all local inflammations, and much more 
so in parts of so much sensibility as the eyes; and you will find 
in all such cases that the pain and inflamation are both aggravated 
by the stimulating effects of cold. Samuel Cooper observes that 
if cold applications be painful, they should be applied warm. Ba- 
ron Pery, in his Memoirs of Military Surgery, also recommends 
not only the eyes but the head to be frequently washed with 
warm vinegar and water, not cold. This bad effect is to be expect- 
ed, when we recollect that the eye is a secreting surface, and that 
cold applications diminish those very secretions which, it is unde- 
niable, should be promoted. In the first years of my practice, I 
adopted this treatment in ophthalmia, but very soon found to my 
surprise, that although lead water might, in some cases, give mo- 
mentary relief, the burning, itching, and pain very soon returned 
with a manifest increase of the inflammation, probably from the 
check given to the discharge. But we may certainly obtain all the 
sedative and beneficial effects of lead without the disadvantage of 
cold applications; applied moderately warm, I have certainly found 
it an useful remedy; i. e. after venesection and other evacuations 
have been prescribed; but before these means of depletion have 
been employed, it is certainly a dangerous prescription and should 
be totally prohibited. In IS 14, a case occurred in this city, 
where very destructive effects proceeded from the application of 
lead water in erysipelas, accompanied with ophthalmia. The fol- 



470 LECTURE XXXVIII. 

lowing is the form in which I make use of this medicine: 1£. acet. 
plumb. 3ss.; acet. distill, gss.; laud. Sij- ; aq. pluvial, gviij. M. 
I usually direct a linen cloth, folded and wet with the liquor, to 
be applied to the part affected, renewing the application when it 
may become cold. But before the system has been depleted, I 
usually have recourse, 

7th. To applications of warm rain water, milk and water, 
to weak vinegar and water, or to diluted sp. mind. §iij. and 
laudanum 3ij., %vi. aq. pluvial.; or where the parts are extremely 
painful, to fomentations of poppy heads. This Dr. Bard found pe- 
culiarly serviceable in his own case; it is also highly recommended 
in the last edition of Cooper's Surgery. After the remarks already 
made, on the effects of opium, it is not improbable that the poppy 
heads were equally serviceable with the soothing effects of the 
fomentation derived from its warmth ; the practice of Mr. Ware 
is certainly favorable to this explanation ; he also advises all his 
collyriato be applied warm. Mr. Dawson (see Nosology, p. 56.) 
also observes, "where the eye is highly irritable and painful, I 
should prefer warm water, applied with a sponge and reserve the 
cold saturnine or similar washes, such as the sulphate of zinc, or the 
muriate of mercury, until the irritation and pain has partly sub- 
sided." Another application which you will find very service- 
able in promoting a secretion from the eyes in ophthalmia, and 
which is well calculated to allay the irritation and to diminish the 
sufferings of your patient, is the application of the common poul- 
tice of bread and milk ; but, for this purpose, it should be boiled 
until it is perfectly smooth, and then spread thin between a fold 
of cambric or fine old linen; this should be laid over the eye, and 
be frequently renewed, say every three or four, at most every six 
hours. Whatever application you may make through the day, 
you will find this cataplasm an excellent anodyne for your patient 
through the night, when the symptoms are usually aggravated. 
Another application, which many physicians prefer for active 
inflammation of the eyes, is a poultice of the slippery elm bark; 
some again make use of an infusion of quince seeds, flaxseed, or 
the pith of sassafras, a teaspoonful to gviij. of water, or common 
barley water. 

These applications are all mucilaginous, and therefore calcu- 
lated to allay irritation in the parts to which they are applied, at 
the same time that they afford a soft defence from the action of 



OPHTHALMIA. 471 

the air, upon the inflamed surface of this very sensible organ. 
The hop poultice, by its anodyne qualities, is also found a very 
soothing and useful application in this disease. But notwith- 
standing all these various applications, in some instances the in- 
flammation continues, and even is increased with a manifest ful- 
ness of the eyes, and thickening of its coats; and perhaps a 
beginning protrusion of the cornea, and an opacity of that coat of 
the eye. In such case it has been proposed by Mr. Wardrop to 
lessen the bulk of the eye, and to take off the tension of the 
inflamed parts by a discharge of the aqueous humour, by punctur- 
ing the corner of the eye with the knife used for extracting the 
lens, and to introduce it at the same part where it is introduced 
for that operation, and to such an extent as to make an incision as 
broad as the knife. Many cases are lately published by that gen- 
tleman, of the success of this remedy. Mr. Ware has also made 
use of it with the best effects, and recommends it to be 'done 
early, to prevent rupture from some parts which might otherwise 
prevent the return of vision. It may therefore be considered as 
a very important addition to the means of diminishing inflamma- 
tion, especially when it involves the internal membranes of the 
eyes, and is likely otherwise to end in the destruction of that 
organ. (See Edin. Med. Jour.) In one case which I attended, in 
conjunction with an eminent physician of this city, I proposed, 
in such protrusion, to discharge the humours of the eye, as I once 
did in a former case, with the best effect. It was opposed. It 
ended fatally. I now exceedingly regret that this mode of punc- 
turing the eye had not been made use of at that time. 

The second indication being fulfilled; i. e. the inflammation be- 
ing removed, we are next to restore the tone of the debilitated 
parts, and to remove the consequences which such inflammation 
may have produced. 

1st. A morbid sensibility frequently remains, attended with a 
lax and distended state of the vessels. A sort of passive inflam- 
mation remains ; the part yet unattended by pain, or the febrile 
symptoms of the first and active stage of the disease. In this stage 
a solution of the sulphate of zinc, composed of the strength of 
one grain to an ounce of rain-water is an useful application, and 
should be frequently applied. 

Let me here guard you against the absurd and unchemical 



472 LECTURE XXXVIII. 

compound of vitriol and lead, made use of by some physicians, 
and recommended, too, even by Dr. Dorsey, in his System of 
Surgery, (vol. i. p. 293.) and I perceive by Dr. Gregory of Lon- 
don. It is like some of Dr. Brown's prescriptions for his mixed 
debility ; i. e. supposing direct and indirect debility, to exist 
at the same time. So you have here the opposite qualities of 
stimulant and sedative in the same prescription : viz. the sulphate 
of zinc and the acetate of lead. Their decomposition ensues, 
and new combinations are formed. 

In your prescriptions, let me advise you always to observe 
simplicity; otherwise your practice is uncertain, and for the most 
part inert. One of the greatest, improvements our profession has 
received, has been the abandonment of the complex farragos 
which made up the prescriptions of older physicians,' and the 
adoption of a more simple mode of administering medicines. 
While the former practice was intended to counteract particular 
predominating symptoms, the latter strikes at the root of the evil, 
by removing or counteracting its cause. In the first stage of the 
disease, if the means of diminishing inflammatory action be indi- 
cated, and lead be preferred as a sedative, make use of it ; but in 
the second stage, when stimuli are called for, use the vitriol, and 
which you will find a valuable stimulus. Many other means are 
employed for the purpose of restoring tone to the debilitated ves- 
sels: a w r ash of brandy and water, cold water alone, the alum 
curd — made by coagulating the white of an egg by alum. 

In the second stage of ophthalmia, when seated in the tarsus, it 
is not unusual for a chronic enlargement of some of the glandulae 
meibomii to remain, constituting the hordeolum or stye, attended 
with fresh inflammation; in other cases, the tumour remains in an 
indolent state, without, inflammation. In these cases, one of the 
best applications to resolve these obstructions, and to restore the 
excretion from those organs, is the white precip. of mercury, which 
is the sub-muriate of mercury and ammonia, the sal alembroth of 
the alchy mists. This is the basis of the celebrated ophthalmia 
ointment of Janin, so much recommended by Cooper and others; 
viz. ft axung. §ss.; bol. armen. 3ij.; prepared tutty, 3ij.; white 
precip. Zi. M. When ophthalmia terminates in the pteryguim, or 
film, covering a part or whole of the eye, and the active inflam- 
mation is removed ; in the first place, with the curved scissors 



OPHTHALMIA. 473 

or knife, remove such portions as can be conveniently detached 
from the subjacent coats of the eye. In other instances, we may 
divide by the knife or the lancet, the principal vessels which may 
nourish such newly formed production. Still some portion will 
remain, obscuring the e)~e, or a part of it. Mr. Ware directs in 
such cases, aether to be applied to the part, by means of a camelV 
hair pencil. Sometimes he adds to it one-third or one-fourth of 
the solution of corrosive sublimate. With these even an opacity 
of the crystalline has been removed. Others again, under similar 
thickening of the coats or films, apply verdigris with sugar; viz. 
1 part verdigris, 6 parts sugar; or red precipitate, I part, sugar 6 
parts; or sugar and alum, equal parts; or sugar and nitre. In such 
case I have seen repeated instances of the removal of those remains, 
by the application of a still more simple remedy — molasses, drop- 
ped into the eye two or three times a day. It probably acts by ex- 
citing the absorbents which have become inactive. The same 
remedy, I recollect, was earnestly recommended by Dr. Shippen. 
When the disease is symptomatic, attend to the cause. If pro- 
duced by syphilis, mercury is the only resource; if the effect of 
scrofula, you must resort to bark, alteratives, seawater, and sea- 
bathing; and use tonics to prevent the return of ophthalmia. In 
this case, both the local and general application of cold will be 
beneficial. 

The diet, in ophthalmia, should be very simple — avoiding every 
thing that can excite the system — avoid light — keep your patient 
in a dark room — protect the eye by a piece of green silk, either 
hung loosely before it, or covering a piece of pasteboard; but 
especially avoid all close bandages — even goggles are too warm — 
they increase both the heat and sensibility of the eye. 



41 



474 



LECTURE XXXIX. 



OTITIS.— ODONTITIS, &c. 



Otitis, inflammation of the ear, derived from ov$, an ear. 

The ear, like the eye, is an organ of great sensibility, more 
especially in children. It derives this sensibility not only from 
the distributions of the portio mollis of the auditory nerves upon 
the internal, and the portio dura, on the external parts of that organ; 
but the sublingual branch of the inferior maxillary nerve, that is, 
a branch of the fifth pair, also by its union with the chorda tym- 
pani, a branch of the portio dura, holds communication with the 
ear, and in consequence of this connexion we are led necessarily 
to attach more importance to the diseases of this organ, because 
through that medium such diseases sometimes affect the brain, 
and indeed the whole system. For an illustration of that con- 
nexion, let me refer you to the valuable work on the diseases of 
the ear by Saunders; the distribution of the fifth pair of nerves 
you will also see beautifully exhibited in the work of Walther, 
and a plate of the same in the Berlin Transactions. Otitis is 
generally considered as an inflammation of the meatus auditorius 
externus. Wilson defines it phlegmasia cum dolore auris interna^ 
saepe cum delirio. But it is not confined, as many suppose, to the 
external ear; nor is Wilson right in limiting it to the internal ear; 
both are frequently involved in the same inflammation, depend- 
ing on the degree of it, the cause producing it, and the habit of 
body in which it occurs. Slighter cases of it, especially from 
cold, will perhaps only affect the secreting surface of the external 
ear. and the inflammation confine itself to the ceruminous 
glands, and the excretories, analogous to the ophthalmia tarsi. It 
produces spongy granulations, (assuming the appearance of a poly- 
pus;) in others it leaves what Saunders denominates an herpetic 



otitis. 475 

ulcerous eruption, and this sometimes such as to close the pas- 
sage, obstructing even the entrance of sound. These cases are 
generally cured by the forceps, injections, ointment of mercury, 
and caustic; while in other cases, it seats itself upon the mem- 
brane covering the tympanum, or even extends beyond it to the 
internal ear, and affects even the membrane lining the mastoid 
cells, and thence perhaps to the brain itself. Accordingly in Saun- 
ders you find cases terminating in the very destruction of all those 
organs; not only showing itself in the ordinary purulent secretion 
which takes place from the external ear, and which perhaps may 
remain for sometime comparatively harmless, but in other in- 
stances the tympanum is destroyed, and the whole chain of bones, 
and the nerves and muscles connected with it, even the very 
membrane lining the mastoid cells is destroyed, and the cells 
themselves filled with pus; followed, says Saunders, in some in- 
stances, by an exfoliation of the external lamina of the mastoid 
process: but this is not all, it not only ends in the destruction of 
the organ of hearing, it also extends itself to the brain, and in- 
volves the whole system in disease, and frequently proves fatal. 
Vogel states, that in this manner it sometimes proves immediately 
fatal on the first da} T , and very often destroys the patient before 
the seventh. The late Mr. M'Kie, of this city, an ingenious and 
promising youth, was thus cut off by inflammation of the brain, 
induced by inflammation of the ear, to which he had been very 
subject from childhood; it ended in a loaded state of the vessels 
of the brain, producing all the symptoms of apoplexy; that ter- 
gescence in all the vessels of the head, was manifest after death. 
But in other instances, this inflammation ends in abscesses and 
tedious ulcerations, with a total destruction of the organ of hear- 
ing. It appears, then, that there is not sufficient importance 
attached to inflammation of this organ; indeed some nosolo- 
gists omit it altogether. Vogel, however, has given it a place 
as a distinct genus, the forty-eighth among his inflammatory, 
calling it, " Inflammatio auris internae, dolor immanis in aure, 
febris, cephalalgia, agrypnia, delirium." With these facts before 
us, we are taught both to give it a place in nosology and to 
give attention to this disease not only as a disease of the ear, 
but, in some instances, as a disease involving the brain and 
the whole system ; for a disease that occasionally terminates 
fatally cannot be correctly viewed in any other light. The 



476 LECTURE XXXIX. 

symptoms of this disease are, pain in the ear; this is very acute 
and distressing, and being seated in parts of great sensibility, and 
sometimes extending to membranes of a dense structure, as those 
composing the tympanum, and the membrane lining the mastoid 
cells, less severe when confined to the ceruminous glands, and 
the excretories: but in either case the pain attendant on inflam- 
mation of the ear is not always confined to the ear itself, but 
affects the side of the head. The general circulation is excited, 
attended with heat, thirst, delirium, coma, &c. The most com- 
mon exciting cause is cold, as the use of a cold bath when 
the body is heated, and persons once having suffered it are very 
liable to returns of it. It is occasionally also produced by other 
causes, as catarrh, scarlatina, cynanche maligna, and syphilitic 
ulcers of the throat. Hence, then, the disease is very properly 
divided into idiopathic, as that from cold, and symptomatic, 
when induced by other diseases, as those just enumerated ; this 
is the most dangerous 



TREATMENT OF IDIOPATHIC INFLAMMATION OF THE EAR. 

Every old woman or nurse thinks she understands this disease, 
and the treatment of it. Not so. Venesection sometimes is required 
in full habits, purges, or emetics, bathing the feet, small doses of 
antimonial wine and laudanum ; laudanum is useful here, as in 
other inflammations seated in parts of great sensibility. Dover's 
powder, or sp. mind, and laudanum; blisters behind the ears, or to 
the neck. These are very necessary and important; the application 
of a mustard plaster, fomentations to the side of the head. Poultices 
of bread and milk and laudanum, or of hops infused in vinegar 
and water, protecting the head at night by a flannel night cap du- 
ring the disease, but not afterwards, as it renders the person more 
liable to cold. If the pain be very severe, injections of warm milk 
and water will be necessary, or warm oil and laudanum may be ap- 
plied in drops, or by inserting a piece of cotton or wool moisten- 
ed with it. The common domestic remedy sometimes has a very 
soothing effect, as the clove of a roasted onion. In some instances 
much injury is done by stimulating and spirituous applications in 
this stage of the disease; for instead of effecting resolution they 
add to the excitement, and induce suppuration, if not the more 



ODONTITIS. 477 

formidable evils, such as the destruction of the ear. or an inflamed 
brain. The diet, during such excitement, should be in general 
simple, as in the phlegmasia?. When resolution is not produced 
and it ends in suppuration, or purulent secretion, as soon as 
the inflammatory stage has subsided, stimulating injections 
are indicated to prevent such discharges from becoming per- 
petual issues or ulcers. The sulphate of zinc, as in ophthalmia, 
I have used with great advantage ; in obstinate cases small 
doses of calomel are said by Saunders to be an important remedy 
for this offensive disease, gr. ij. daily. Turpentine and oil equal 
parts, a few drops morning and evening, occasionally injecting 
and cleansing the ear with soap and water. General tonics are 
also indicated, as the bark, bitters, cold bathing, either sea-bathing 
or the shower bath ; washing the head and ears daily with cold 
water is also calculated to lessen morbid sensibility and thereby 
remove that liability which exists to returns of the complaint, 
whereas the common practice of washing the head in warm water., 
bathing the feet two or three times a week in warm water, adds to 
the sensibility of the system, which invites a return of this or 
other inflammatory complaints. When the disease has been of 
long duration, it will be useful both in the cure, as well as to 
guard against the evils which may arise from checking a dis- 
charge that the system has become accustomed to, to introduce a 
seton, to keep up a soreness behind the ears, or to establish a new 
irritation by issues in the arms. 

ODONTITIS, 

More properly than odontalgia denotes the nature of the dis- 
ease we contemplate under this head, for pain is only one of its 
symptoms. Dr. Cullen denominates it "Rheumatismus vel ar- 
throdynia maxillarum a carie dentium." This is a very deficient 
description of this disease; besides caries is but one cause of it; 
cold, plethora, gout, teething, also frequently induce it. Accord- 
ing to Wilson and Thomas, too, it is exclusively a local disease; 
and by Thomas it is actually so placed among his locales. It is 
certainly one of the phlegmasia?; for it is attended with inflamma- 
tion of the part, and usually with a general fever of the whole 
system. For the most part it comes on with pain of the part, and 
and some symptoms of general fever ; but also very frequently 
41* 



47S LECTURE XXXIX. 

the pain affects the whole side of the face, extends to the ear and 
the eye of the same side, involving the whole side of the head, 
the irritation following, I may say, the whole extent of the fifth 
pair of nerves in all its branches, to the eye, the whole of the up- 
per and lower jaw; and it is attended too with manifest tumor 
and other symptoms of active inflammation; and these are accom- 
panied, in many instances, with great heat, great thirst, increased 
action of the arterial system, and all the symptoms constituting 
inflammatory fever. In some instances, the inflammation of the 
part also, like other inflammations, ends in abscess, which is pain- 
ful and generally confined to the gum ; but sometimes it extends 
to the cheek, and discharges externally; in other instances it in- 
volves the membrane lining the antrum highmorianum and ends 
there in suppuration. Frequently it confines itself to the jaw, 
destroying the periostium, and producing a caries or ulcer of the 
bone itself, and this being connected with the external soft parts, 
unites them in one mass of disease, discharging the matter of the 
parts affected externally; this is vulgarly called (i tooth-evil." I 
knew a lady who, on a visit to the eastward, took cold, which 
she neglected as a mere tooth-ache; the consequence is a disease, 
which not only will disfigure her face through life, but render 
those parts liable to repeated attacks, whenever she may be ex- 
posed to cold. Can such disease then be disregarded by the prac- 
titioner? 



CAUSES. 

Odontitis usually is ascribed to a caries of the tooth. The nerve 
of a tooth that is decayed being exposed, doubtless is in condition 
to be easily acted upon by any exciting cause that may be applied 
to it; but caries of itself is rarely the exciting cause of such at- 
tacks of inflammation; it only acts by predisposing the parts to 
be excited by cold, by acrid materials, or by the alternate action 
of heat and cold; either by changes of the atmosphere, or by food 
and drinks taken either of too hot or too cold a, temperature. In 
such state of the parts, cold is the usual exciting cause of odonti- 
tis; its action too is very much dependant on the general irrita- 
bility of the system. Hence, females are more frequently the 
subjects of this disease than males, and especially those of a ner- 
vous temperament ; in pregnancy too, when the natural sensibility 



ODONTITIS. 479 

of system is increased, this complaint is still of more frequent 
occurrence ; owing probably, in this case, to the plethora of the 
blood vessels, as well as greater sensibility of the nervous system 
and of the particular part. In some instances, however, tooth-ache 
and pain of the nerves of the face will occur without any previous 
destruction of the teeth; a fact which shows that such pain arises 
from pressure of the distended vessels upon the accompanying 
nerves. But a woman that has a carious tooth, I may say, is sure 
to have tooth-ache in pregnancy; for the most part even then it is 
removed by the lancet ; but in some cases extraction alone affords 
relief. I know a lady that has thus lost a tooth with every child 
she has borne; her teeth were carious, but they were only painful 
to her during her pregnancy; they were then a source of conti- 
nual suffering; they were the irritable part, for she experienced 
no breeding sickness or other evils of pregnancy; by her tooth- 
ache alone she knew herself to be with child. There is another 
affection of these nerves frequently met with that is allied to 
odontitis, I mean neuralgia, or tic douloureux, as it is commonly 
called when confined to this part, either the lower or under jaw, 
or the side of the face, it was called by Dr. Fothergill, a painful 
affection of the face, and under that appellation he describes it. 
(See his works. See Appendix to Thomas.) In such cases, it 
has been ascribed to lithiasis, or a floating gouty matter in the 
system, because it occurs frequently in gouty habits of body, an- 
other word for a full habit. Here too is another example of an 
imaginary virus in the system, floating about, and fastening itself 
upon the brain, upon the stomach, upon the face and jaws, or upon 
the great toe ; gout, cancer, and scrofula constitute a trio that, in 
the present fashionable views of pathology, disgrace our profession 
when we view it as a branch of science. Dr. Fothergill considered 
this to be the cause; but as we shall see that in gouty habits there 
is a combination both of sensibility and plethora, we need not 
have recourse to any peculiar humor to account for this disease. 
Indeed, I consider lithiasis, gout, and those painful affections to 
be frequently the produce of some causes, both predisposing and 
exciting ; for it is in such fulness of habit that we look for earthy 
or bony deposits, in the different parts of the body, and in such 
habits, especially when rendered irritable by free living, we also 
look for these nervous and inflammatory affections. It is for the 
same reason that such affections of the teeth and gums are the at- 



480 LECTURE XXXIX. 

tendants on dyspepsia, and every dentist will tell you the fact that 
diseased teeth, the acid stomach, the foul tongue, sordes accumula- 
ting about the teeth, the offensive breath, are usually associated; not 
that the acid generated in the stomach is the immediate cause of 
caries of the teeth, but that the same condition of nervous system 
that predisposes to affections of the stomach, also renders the fifth 
pair of nerves liable to be acted upon by the same exciting causes 
of disease, as those of the stomach and its vicinity. Hence we 
find an early decay of the teeth connected with a general debility 
of constitution. In the present case cold, or rather the alternate 
operation of heat and cold, are the more frequent causes of odon- 
titis. For this reason, too, it is that we see this complaint, like 
other inflammatory diseases, the attendant on a variable climate; 
not so in the uniform temperature either of a hot or a cold cli- 
mate. The negroes of Africa are remarkable for their fine teeth ; 
so too are the inhabitants of northern countries : a Scotchman is 
rarely found without good teeth, and those too pretty early cut. 
(See Gait's Sir Andrew Wiley.) The treatment should be as in 
other phlegmasia^. In plethoric habits of body, and especially in 
pregnancy, venesection is necessary. Cathartics, salts, numerous 
cases of it are cured by this alone, without extraction of the 
tooth. This is certainly desirable, where the tooth is not 
much decayed; blisters in some cases necessary; warm drinks, 
and foot-bathing to relax the surface. With the same view, the 
spiritus mind, and laudanum may be occasionally administered, 
both to lessen pain and to remove fever ; at night, an anodyne is 
especially useful, for at that time the sufferings of the patient are 
most severe, as is usually the case in most of the phlegmasia?. 
The part itself should be kept warm ; fomentations of vinegar and 
water, or a vinegar poultice to the jaws, rinsing the mouth fre- 
quently with a gargle of vinegar and water, or a decoction of figs, 
and if suppuration threatens, in the form of a gum-boil, this is also 
very much facilitated by the same gargle; a poultice of bread and 
milk applied to the cheek will also assist in promoting suppura- 
tion. A prejudice exists against the use of this application, lest it 
induce suppuration externally: this is not well founded, if atten- 
tion is paid to temperature in the application. If the tooth be 
much decayed, as soon as the inflammation is either removed by 
resolution or by suppuration, whether internally or externally, 
extract the tooth ; in the latter case it is indispensably necessary 



ODONTITIS. 481 

to close the wound. In the tooth evil, spirituous applications, a 
fold of linen, wet with rum; in some instances a projection of fun- 
gous flesh will require caustic daily, and rum. But extraction of a 
deca}^ed tooth is also useful, to prevent subsequent attacks of inflam- 
mation of the jaw. It is the common opinion, and well founded too, 
that it prevents the other teeth from becoming affected; not that 
caries beget caries, but that irritation is thereby kept up in the 
jaw, and that the other teeth, that are now sound, are liable to be- 
come carious by the same causes that affected the first. For this 
reason, the sooner a diseased tooth is removed the better ; if the 
tooth be not much affected, and the caries small, it will be pre- 
served by excluding the air and other materials from it, by plug- 
ging it with tin or gold foil, previously cauterising the nerve. 
The pain of this process is very trifling, and prevents a great deal 
of suffering by destroying the sensibility of the nerve. How are 
these affections of the teeth to be prevented ? and when once af- 
ected, how can we prevent the recurrence of these complaints ? 

Avoid the exciting cause. Avoid the habitual use of hot drinks. 
The practice of smoking, too, for the same reason, should be pro- 
scribed; for, notwithstanding the anodyne effects of tobacco, the 
hot air, especially from a segar, cannot fail to affect the nerves, as 
well as heat applied in any other manner. But if smoking must 
be permitted, the long Dutch pipe, or the Hooker, is less excep- 
tionable than the segar, as the air is less heated when it reaches 
the mouth. The most effectual means of guarding the jaw against 
these inflamatory affections are, to cleanse the mouth daily, with 
cold water, and the brush, and especially after eating, to prevent 
lodgments of acrid materials, or which may readily become so, 
and thus excite irritation. A variety of dentrifices are in com- , 
mon use, which are supposed to be useful, both in preserving the 
teeth, and to guard against these inflammatory affections, to which 
the jaw and gums are liable. Some of these are really innocent 
and useful; but others are positively injurious. All the mineral 
acids are injurious, for they very readily decompose the teeth. 
The salt and water recommended by Wilson, should be totally 
prohibited on account of the muriatic acid it contains; yet some 
persons are in the habit of using salt as the daily dentrifice; others 
again, make use of snuff. I do not know that this injures the 
teeth, but it certainly, in some cases, affects the nervous system, 
produces dyspepsia, and has led to intemperance. Charcoal is a 



482 LECTURE XXXIX. 

common dentrifice. Where the mouth is offensive, from bad 
teeth, or diseased gums, it is peculiarly proper, as it counteracts 
the offensive breath which they occasion ; yet some dentists ob- 
ject to it on account of the pyroligneous acid which it contains; 
and they allege that by this acid it actually injures the teeth. This 
is certainly contrary to the experiments recently made on this 
subject. The best dentrifice, I believe, is that which is composed 
of calcareous earth, or powdered bone. Thomas recommends a 
composition of Bol armeniac and calcined bones or horns ; aa. 3ij. 
But besides cleansing the teeth of the foul materials that collect 
about them, it is also useful to preserve the gums in a sound and 
healthy state; otherwise they become of a very loose texture, and 
are detached from the teeth, which thence become loose in their 
sockets. One of the most beautiful sets of teeth I ever saw, was 
thus loosened. Not a single tooth was in the least affected. The 
lotions usually made use of to guard against these affections are, 
brandy and water, rum and water, with the addition of spirits of 
lavender, tincture of myrrh and water, or the combination, recom- 
mended by Thomas; viz. tinct. cort. per. gij.; tinct. myrrh, Xss. M. 
These things, although they may appear of inconsiderable mo- 
ment, merit a portion of your attention : for you will be frequently 
as physicians, interrogated on these points, as w T ell as called upon 
to cure the diseases that the neglect of them occasions. Recol- 
lect the reply of the celebrate 1 painter Raphael. He was once 
asked, by what means he had reached such perfection in his art? 
His reply was: " I think nothing that belongs to it beneath my 
attention." This reply should be recollected by every student 
of medicine who wishes to excel in the practice of phasic. Every 
subject which it presents has claims upon his attention. 

Inflammation of the gums, attendant on teething, may also, 
with propriety, be embraced under this head, and deserves our 
notice. The irritation arising from cutting teeth, manifests itself 
in various ways ; and in some instances, is attended with very 
serious consequences. The child usually begins at the age of 
about four months, to cut its teeth. In some instances, they ap- 
pear earlier, and in others, much later. The child first manifests 
this irritation, by putting the fingers in the mouth; by listlessness; 
the gum is swelled and thickened; it is also hot to the mother's 
breast; the irritation invites an increased flow of blood to the 
part; the heat of the mouth is increased. The child is restless, 



ODONTITIS. 483 

heated, and feverish; starts in its sleep; the cheeks are flushed; 
skin generally hot and dry, especially in winter, when the per- 
spiration is less. On this account it probably happens, that chil- 
dren cut their teeth with more difficulty in winter than in summer; 
for perspiration, which is most abundant in the warm season, 
certainly obviates much of the fever attendant on teething. The 
stomach is disturbed by vomiting ; the matter ejected is acid and 
hot ; the breath frequently offensive ; the milk is thrown up fre- 
quently, and curdled. This disturbance of the stomach is attended 
with flatulence, griping in the bowels, drawing up of the lower 
extremities ; green evacuations ; and sometimes diarrhoea, and 
symptomatic dysentery ; i. e. more or less of tenesmus, and mu- 
cous discharges, tinged with blood. In some cases, the fever of 
teething is carried off by an increased secretion from the mouth; 
the child slavers or snivels, almost as in salivation from mercury. 
In this case, it is oftentimes relieved by this increased secretion. 
In other instances, an increased discharge, taking place from the 
bowels, also affords it relief — (hence the remark of Dr. McGrath, 
in his Scotch dialect, that the child that is teething, must slabber, 
purge, or die.) In some cases, too, it is relieved by an eruption 
appearing behind the ears. The eruptions sometimes take place 
in patches on the cheek, or on the arms and legs, hence called the 
strophulus confertus, by Dr. Willan. The eruption is so thick, 
that it resembles the rash in measles, tooth rash. Dr. Good erro- 
neously calls it the red gum — this disease is confined to the erup- 
tions immediately after birth — and, as in other eruptive* fevers, it 
sometimes proves critical. In other cases, again, the inflammation 
of the gums produces ulcers in the mouth: the tongue, the inside 
of the cheeks, and the gums are covered with small corrosive 
ulcers, commonly called the cankered sore mouth — the cancrum 
oris, as Dr. Coates calls it — and renders the breath of the child 
excessively offensive. Sometimes the irritation vents itself upon 
the glands about the jaw or the neck. They swell, and frequently 
proceed to suppuration. But the fever, not terminating by some 
of the evacuations that have been mentioned, or in the eruptions 
or abscesses, a determination to the brain, ending in hydrocepha- 
lus, is the consequence of the continuance of fever. "Hydroce- 
phalus interims," says Mr. Badingfield, " arises from no source of 
irritation more frequently than from painful and protracted den- 
tition." (p. 75.) This disease is, I believe, frequently thus pro- 



484 LECTURE XXXIX. 

duced. But a still more common effect of teething is convulsions: 
yet common as it is, the cause is oftentimes most strangely over- 
looked by practitioners. 



TREATMENT. 

If the teeth are protruding, or ready to burst through the in- 
flamed gum, divide the gum freely. No evil can come from such 
division — no greater resistance to the teeth, as the French allege, 
from the cicatrix, for it is an established truth, that absorption 
more easily takes place of recently formed parts. (See Fox on 
the teeth 5 3d edition, p. 86, 87.) "Upon a free division of 
the gums we must chiefly rely for the prevention or removal 
of the diseases to which children are exposed by dentition. In 
less than two hours after the operation," says Mr. Badingfield, 
" I have seen the most violent symptoms diminished, and hy- 
drocephalus internus arrested in its progress, convulsions cease, 
symptomatic fever subside, and in a few days cutaneous erup- 
tions disappear." (Compend. of Practice, p. 75.) We thereby 
spare the little sufferers many distressing and painful moments. 
I have seen them actually gratified in the operation, as they 
evinced by the manner in which they submitted. In dividing 
the gum, too, where a dens sapiential is pressing upon it in the 
adult, we sometimes give it instantaneous relief. 

Manner of doing it. — A sharp instrument should be drawn in 
the direction of the tooth — feel it distinctly. 

The discharge of blood is also useful. But if the teeth are not 
so forward, a different treatment is to be pursued ; and in this 
nature almost points out the course to be observed. Increase the 
evacuations by the mouth, by the bowels, or by all combined. 
Magnesia and rhubarb night and morning. The advantage is to 
correct acidity, as well as to open the bowels ; but in case of 
more than ordinary costiveness, a dose of castor oil, and an ene- 
ma should be given ; or a dose of calomel and jalap may be ad- 
ministered. Afterwards procure two or three stools a day, by 
the use of calcined magnesia. To diminish fever, also relax the 
surface by warm bathing, general or partial ; antimonial wine, 
either to the degree of exciting full vomiting — say fifteen or 
twenty drops — or as a diaphoretic; gutt. x. or fifteen every two or 



ODONTITIS. 485 

three hours. Or small doses of ipecac.; gr. i.; rhei, gr. ij. M. ; 
once or twice a day. Perhaps you have an aphthous ulcerated 
mou th — magnesia and the following detergent powder of Barnet, 
and loaf sugar — 1 borax, 2 sugar will be of service. But if the ul- 
cers appear like chancres, destroying the texture of the parts, have 
recourse to a solution of the sulphate of copper: gr. iv. to ^i. or gr. 
vi. Touch the parts frequently, say three or four times a day. A 
wash of yeast, water, and honey, with a lump of borax dissolved in 
it, also affords great relief in these painful ulcerations. But perhaps 
you are first called upon to see the child in convulsions. At this 
age, say from four months to two years, always recollect this source 
of irritation of the mouth, as well as in the bowels. But it is a 
great abuse of opiates when they are given to allay restlessness 
in children, without previous evacuations ; and in this case they 
frequently serve to beget convulsions. Recollect that convul- 
sions may arise from irritation from fever. Administer an opiate 
instantly, to suspend the irritation. The aq. ammon. gtt. v. to 
gtt. x. has been found useful. Warm bath sometimes — while the 
bath is preparing, an enema, and divide the gums. By this you 
remove the cause. Is the child relieved, give it a dose of purga- 
tive medicine. If the child habitually is liable to convulsions, 
as is the case sometimes, with every tooth, apply blisters behind 
the ears; or let the child wear a piece of tape covered with blis- 
tering ointment; or put some strong mustard behind the ears, or 
savin ointment. Like the natural sore ear, this artificial excite- 
ment will afford similar relief. Venesection, if of a full habit; 
afterwards air and exercise will generally, with an open state of 
the bowels, afford permanent relief. Indeed the confinement of 
the infant to the nursery, and the want of exercise in the open 
air, by the relaxation it produces, renders the child more liable to 
the different causes of irritation, and occasions it to suffer much 
more when indisposed than it otherwise would do. Sometimes 
it may be necessary even to administer some tonic, if the child 
be very much reduced. Chalybeates, gr. iv. or gr. vi. and bit- 
ters; elix. prop, if costive. Cold bathing is also among the best 
means of imparting vigour to a delicate child; for delicate children 
are usually the greatest sufferers from teething. 



42 



486 



LECTURE XL 



PAROTIS. 



Ctnanche parotidcea, or as it is vulgarly called the mumps, 
is a contagious pyrexia which chiefly appears in an affection of 
the parotid gland; which gland receives its name of parotid, from 
its vicinity to the ear, being derived from the two Greek words 
jtapa, near, ov$, the ear. This disease, like other contagious dis- 
eases, is occasionally epidemic. For the most part it is so slight 
as to require little more than confinement and abstinence, with 
some mild cathartic, and perhaps a liniment and piece of flannel 
to the part affected. But in some cases it is more severe, both in 
its general effects upon the system, as well as in the part affected 
and its vicinity. It is most usually epidemic and manifestly 
contagious; but is universally met with as a sporadic disease 
attributed to cold. In some cases the general fever is severe, 
attended with considerable determination to the head, showing 
itself in delirium and other symptoms denoting an affection of the 
brain, and as stated by Dr. Cullen, in some cases it has proved a 
fatal disease. In such violent cases more active general treat- 
ment is called for. Again, in other cases the tumour of the part 
is so great as to end in abscess of the parotid gland, or terminates 
in a scirrhus affection of it; and occasionally the tonsils and 
neighbouring parts partake of the inflammation insomuch that 
you can scarcely determine which is the primary disease. Where 
either the general inflammatory fever is violent, or the local symp- 
toms are severe, have recourse to venesection, active purges, the 
volatile liniment, a blister applied over the part affected; and in 
young persons emetic medicines, become necessary. Afterwards 



MA6TITIS. 487 

small doses of antimonials and other relaxing sudorifics should be 
continued until the violence of the disease be subdued. Leeches 
are advantageously employed, and blisters, as in ordinary buboes. 
Should the inflammation of the parotid or neighbouring parts ter- 
minate in abscess, notwithstanding the general and local anti- 
phlogostic treatment, soft poultices and other means of facilitating 
the secretion of pus, should be employed ; but this event is not 
likely to happen, if the physician does his duty in the early stage 
of the disease. Usually these active measures are not called for — a 
mild cathartic, a volatile liniment to the throat, and other parts 
affected, fomentations of vinegar and water, poultices of hops, with 
tepid drinks and the pediluvium are all that are necessary. In 
about four days the disease disappears. Some cathartic medicine 
should now be prescribed at the termination of the tumour of the 
parotid, and the subsidence or disappearance of the general febrile 
symptoms: otherwise it is not unusual for the mumps to be suc- 
ceeded by an affection of the breasts in women, or of the testicles 
in men, so peculiar is the operation of this disease upon the glan- 
dular system. A case is related by Hamilton, in the Edin. 
Trans., where the testicle subsequently was carried away, leaving 
the tunica vaginalis an empty bag ! Active measures are taken 
in the first stage, and upon the disappearance of the disease; but 
where purgatives are employed these sequelae are not usual. In 
some cases a transfer of inflammation, even to the brain, has taken 
place, constituting an active inflammation of that organ, and which 
demands all the active treatment called for in idiopathic phre- 
nitis.* When these additional local affections supervene, further 
depletion, emetics, fomentations, &c, as in the treatment of idio- 
pathic inflammation of these organs, must be had recourse to. 

MASTITIS. 

Inflammation of the breast and inflammation of the glands of 
the breast, or mamma, attended with pain, tumour, redness, and 
if the woman be suckling, a diminished secretion of milk, and 
fever of the synochal type. The term mastitis is derived from jtaj-oj, 
a breast. Besides the characteristic symptoms just mentioned, it 

* See the History of Mumps on board the ship Ardent, in Nov. 1807, by Mr. 
Noble, related in Edin. and Surg. Journal, July, 1808. 



488 LECTURE XL. 

is accompanied with the usual characters of fever, viz: a chill, of 
sense of coldness, and followed by a stricture upon all the excre- 
tions, particularly of the lochia and of the milk, as well as of the 
skin and other secreting surfaces. As the breast contains a great 
deal of cellular matter, both covering it, and distributed through- 
out the body or glandular portion of it, there is a great tendency 
to suppuration; for such is the sensibility of this organ, and pecu- 
liarly after parturition, when such affection of the breast is of 
most frequent occurrence, that the current which sets to the part 
is very great, and the distention it produces is both very sudden 
and exceedingly painful. If, however, early and active measures 
be adopted in the commencement of the disease, resolution is also 
a frequent termination of the inflammation that affects this organ. 
Another tendency of this disease is that of scirrhus or permanent 
chronic obstruction of the glandular part of the breast ; but this 
is the more frequent occurrence late in life, and after the cessation 
of the menses, and oftentimes is the result of intemperance. Such 
obstruction, too, frequently ends in a subsequent ulceration, called 
cancer. But the acute disease of the breast, now more immedi- 
ately under our view, takes place most geuerally in women soon 
after parturition, and during the period of suckling. In one case 
I have known it to proceed to abscess before labour. It ended 
well, and the lady makes a good nurse. In another the abscess 
did not form until labour had taken place. And we may thence 
consider the debility and sensibility which belong to this condi- 
tion as in a peculiar manner predisposing to such inflammation. 
A sanguine temperament and plethoric habit, are also among the 
predisposing causes of this disease. The milk generally appears 
in the breast of lying-in women about the third day after de- 
livery, except where they are unusually full habited, and have 
already suckled many children; in such cases the milk appears 
the first day, and sometimes even a few days before labour. Not 
so in the first child bearing — a few days, sometimes even five 
elapse before the milk vessels are sufficiently developed to pour 
out a well formed milk. The first discharges are more of a 
serous nature — nevertheless it is a good practice to put the child 
to the breast in the first twenty-four hours after delivery, that the 
breast may perform its functions as soon as possible; for in the 
mean time, especially after the third day, it is tumid, painful, and 
distressing, and usually attended with fever, which is thence de- 



MASTITIS. 489 

nominated a milk fever, or the fever attendant upon the first 
coming of the milk. By early application of the child to the 
breast and paying attention to the bowels, milk fever may often- 
times be prevented altogether; at least it will be rendered much 
more moderate, both in violence and duration. In this state, too, 
the local fulness of that organ predisposes to inflammation upon 
the least imprudence in diet, change of dress, or exposure to cold. 
But when the milk has flowed freely, and the breast is inordi- 
nately full, it is also liable to inflammation; upon the least impru- 
dence or neglect. Under such circumstances the usual exciting 
causes are, 1st. Neglect to empty the breasts. 2d. Soreness of 
the nipples. This is common with a first child. It may be pre- 
vented by washing with rum or brandy during the last month of 
pregnancy. When it occurs, lead water, borate of soda and 
brandy, or alum in brandy, may be used as lotions; and the breast 
should be defended by a nipple shield. 3d. Fever, the effect of 
cold. 4th. Costive state of the bowels. 5th. Suppression of 
the lochial discharge, whatever may be its character. 6th. The 
paroxysm of an intermittent. 7th. The premature use of ani- 
mal food instead of the abstemious diet necessary during the first 
week after parturition. 8th. The excessive use of hot drinks, 
spirituous and vinous drinks, gin, panadas, caudle, and those too 
highly spiced, are frequent exciting causes of this disease, espe- 
cially among the lower classes, and among the more fashionable. 
9th. A heated atmosphere, closed curtains, an excessive quantity 
of bed clothing, and especially too much covering of the breasts 
themselves with flannel, and the subsequent exposure of them to 
the air, which is unavoidable in nursing, also frequently produce 
an inflamed breast. 10th. Too much company and conversation, 
depriving the lady of her necessary rest, and by positively excit- 
ing her nervous system will frequently be the cause of fever, and 
consequently render this very sensible and irritable organ, the 
seat of irritation and consequent inflammation. Under these cir- 
cumstances, the milk ceases to flow, the breast becomes hard and 
swelled, and very sensible to the touch; the whole system shows 
the febrile state, and the other secretions being interrupted, the 
whole excitement that is the result vents itself upon the breast. 
What is now to be done ? or rather, let us ask first, what is 
usually done? A most preposterous practice prevails in the sick 
room upon these occasions. One of the first applications usually 
42* 



; 

490 LECTURE XL. 

made, is that of applying a composition of rum or brandy and 
pepper to the parts, the oil of mint, or perhaps a stimulating 
plaster with nutmegs, oil of mace, and most usually with the view 
to allay the pain that the poor woman suffers; and in order to 
counteract the chilliness and sense of coldness attendant upon the 
first stage of the disease, the nurse administers the usual favourite 
potation on these occasions. The cup of hot gin toddy, and that 
perhaps, rendered still more stimulating by combining with it 
some stimulant herb, as the tansy, mint, or rosemary. On the 
contrary, instead of these local and general means of adding to 
the excitement of the system in this disease our indication is as in 
the other phlegmasia^, to diminish the volume of blood flowing to 
the part, to relax the system, and by restoring the various excre- 
tions to divert the excitement from the part affected. And 
such is the sensibility of this important organ, and such is 
the sensibility of the whole frame under these circumstances, 
that we must be active in our means of accomplishing these 
objects or we may be too late; abscess, scirrhus, and sometimes 
sphacelus, and the total destruction of the breast may be the re- 
sult. In the forming stage a cathartic, a bolus of calomel, and 
attention in emptying the breast by the child, or by other means,* 
will oftentimes put a period to the inflammation ; but if the in- 
flammation be considerable when the physician is first called upon, 
other means must be resorted to, as — 1. Venesection in full ha- 
bits, and leeches; 2. The bowels must be relieved by salts, castor 
oil, calcined magnesia, or a dose of calomel and jalap; these, suc- 
ceeded by some of the usual diaphoretic medicines, as the anti- 
monial solution, sp. mind, and laudanum, antimony and calomel, 
aided by the moderate use of tepid drinks. When these means 
have been directed and the tumor and inflammation continue, 
blisters are also very useful and necessary in counteracting the 
inflammation. Dr. Smith, of Rochester, informs me he has used 
them with great success in preventing suppuration. This gentle- 
man was our pupil, and does great credit as a practitioner to the 

* Should the child give pain, the nurse must apply her own mouth, or glasses 
must be employed. Some have recourse to the application of a young pup to the 
breast. In this city there are nurses who make this their living ; and go about for 
this express purpose. One woman more celebrated than the rest, has had her 
teeth drawn to qualify her for this employment, and lives altogether upon breast 
milk. 



MASTITIS. 491 

school in which he was educated. He was not one of your 
fashionables, who prefer their breakfast to a lecture. He was al- 
ways at his post. He now reaps the reward of his talents and his 
industry. * Fomentations of vinegar and water, or a soft poultice 
of bread and milk, or of hops and vinegar, laid lightly upon the 
parts, and of moderate temperature; these frequently disperse 
such accumulations; or in slighter cases, covering the breast with 
a plaster consisting of wax and oil so united that they are of soft 
consistency. Apply a blister if not soon relieved. The diet in 
this active stage of inflammation should be strictly antiphlogistic, 
abstaining from every possible source of excitement in this very 
susceptible state of the whole system; no less attention should be 
paid to the regimen of the patient. You must have regard to the 
temperature of the apartment, of the drinks, and of the local applica- 
tions; forbid company and conversation, light, noise, and all do- 
mestic business and concerns. If the tumor should not be dis- 
cussed but go on increasing, and symptoms of approaching sup- 
puration show themselves, well boiled poultices of bread and 
milk, with an additional quantity of ground flax-seed should be 
immediately applied, or a poultice of the elm bark, (ulmus fulva,) 
until it be dispersed, or suppuration shows itself at a particular 
part. An early and free opening to discharge the matter should be 
made up and down : why ? remember the peculiar structure of a 
gland; if the matter be retained the disease continues, and fre- 
quently ends in the destruction of the organization of the breast. 
This may be prevented by a free incision, and the pain is nearly 



* I have received the following- letter from him on this subject : 

"New York, January 31, 1822, 

" Dear Sir : — Without apology I take the liberty of calling your attention to 
a remedy for mastitis, which I do not recollect to have heard you mention while 
lecturing- on that subject; and I do it, sir, the more willingly, believing it almost 
a specific when applied early. I allude to blisters. The mode in which I have 
used them is, after general and local bleeding if required, to encircle the whole 
basis of the mamma with an emp. epispast. from two to two and a half inches 
wide, to remain until free vesication is produced. For the last four years, during 
which I have frequently applied it, when used early, and aided by the usual auxi- 
liaries, I have not seen an instance of suppuration to follow. And instead of my 
patients complaining of its being a cruel remedy, they represent its operation as 
being comparatively mild, for it speedily diminishes the pain and irritation of the 
organ. Respectfully yours, 

"A. G. SMITH." 



492 LECTURE XL. 

the same whether the incision be large or small; poultices should 
be applied for a few days after opening, to diminish the inflam- 
mation, and to facilitate the discharge, but no violence should be 
made use of in effecting the discharge.* The discharge plentiful 
and the inflammation removed, then use plasters of wax and oil, 
soap cerate, or a mercurial plaster, and perhaps a dose or two of 
gentle purgative medicine, or a few grains of calomel and anti- 
mony may be occasionally administered if you suspect any thing 
like a chronic obstruction of the gland. It is a good rule to 
return gradually to a more full diet, otherwise before the local 
excitement subsides there is danger of renewing the inflammation, 
and of having more abscesses formed. But in some cases, from 
want of a proper and free opening of the breast, from repeated 
attacks of inflammation, or perhaps from the fulness and obstruc- 
tion that succeed to the natural cessation of the menses, or from 
sympathetic connexion with a diseased womb, you are called 
upon to prescribe for a more permanent disease of this organ; the 
breast is hard and unusually full, the patient complains of acute 
lancinating pains through the body of it, the glands of the axilla 
are enlarged, constituting a scirrhus or concealed cancer, or per- 
haps an active inflammation has been produced in it, commonly 
but improperly called chronic inflammation, and ulceration has 
been the result: in other words an open ulcer exists. In this case 
your only resource is the extirpation of the glandular portion of 
the breast — not a part of it but the whole of it, agreeably to the 
very important rule of Professer Richter, of Gottingen. Save 
the skin if possible, that is, if not diseased, but let all the glandular 
part of the breast be removed; the consequences otherwise are, 
a disease of the remainder of the gland; the inflammation created 
by the operation has probably too some share in producing it; 
besides, the pain of the operation is nearly the same whether the 
whole or a part be taken away, and the remainder of the breast 
is of no use even if not afterwards diseased. I have operated in 
fifteen cases. In the first I removed only the part affected. I 
had afterwards to remove the remainder. In all the others I took 

* Let me here notice in a word, another abuse of the same nature in the sick 
room. I mean the practice of nurses in the management of the small tumors of 
the breasts of new born infants. Squeezing them to discharge supposed milk, 
and applying rum and pepper and strengthening plasters, instead of the soft poul- 
tice, or wax and oil plaster. The violence of nurses generally produces abscesses. 



MASTITIS. 493 

away the whole breast. I need not detain you with observations 
on the mode of operating; all this will be delivered in another 
department of this college by the able and practical professor of 
surgery. There is a great advantage in exposure of the part, to 
the air after the operation, lest hemorrhage prove troublesome. 
See my paper on the advantage of exposing wounds to the air; 
(Medical and Philosophical Register;) that is, immediately after 
the operation, to guard against the return of hemorrhage by a 
more permanent contraction of the vessels; the parts are then to be 
brought in apposition and secured by well made adhesive plasters, 
and a light compress of patent lint laid over the whole wound, 
both for the purpose of preserving a comfortable degree of warmth 
and to absorb any discharge that may take place from the wound. 
But it not unfrequently occurs that an active inflammation takes 
place in the part and its vicinity, producing considerable tumor, 
heat, and pain. In such case bathing the parts affected with weak 
vinegar and water, or a light simple poultice laid over the tumor 
will be useful; it should be thin, moist, and light; the bowels 
should be kept easy, and the strictest abstinence enjoined. But 
after a few days, say five or six, have elapsed, and the inflamma- 
tory symptoms have been subdued, and the same is evidenced 
by a discharge of serous and a mixture of sanguineous and puru- 
lent matter, it will be proper to remove the dressings, to bathe the 
parts with soap and water and rum, to renew the plasters, and the 
patient to return gradually to her accustomed diet. The part 
should be dressed daily, and to promote a healthy growth of the 
parts within, it will be proper to have recourse to the bark, bit- 
ters, or some other tonics, with the moderate use of porter, &c. 
Such is the practice I have pursued in a great number of cases, 
and with the most favourable results; but to the practice inculca- 
ted by Richter, that of removing all the glandular portion of the 
breast, I ascribe the patient's escape from all subsequent cancer- 
ous affections, and which, as I have before remarked, clearly 
shows that these affections of the mammae, do not proceed gene- 
rally from that vice of the constitution to which they usually are 
ascribed. 



494 



LECTURE XLI 



CATARRH, OR A COMMON COLD. 



This in itself is, for the most part, a disease comparatively of 
little importance, but in its consequences, if it recur frequently, 
or be neglected by the patient or practitioner, is of very serious 
import, and brings in its train other diseases, which inevitaby 
prove fatal. Catarrh I believe to be the parent of more consump- 
tions than all the other diseases collectively to which that disease 
has been ascribed. Gregory, of London, treats it as of too little 
importance, and without proper lines of demarkation between its 
different species. McGrath, when sent for to a patient ill of a 
cold, was told by the sick man that it was nothing more than a 
common cold ; he replied, with much good sense, " Man, what 
could you have worse? would you have a plague ?" He was 
doubtless aware of the alarming consequences to be apprehended 
from this cause; and indeed it may be said, with truth I believe, 
that colds have destroyed more than the plague. In this manner 
I have frequently known a neglected cold end in phthisis, and 
in those, too, in whom there was not the least predisposition to a 
pulmonary disease. Seeing, therefore, that such is frequently the 
termination of a common catarrh, it merits our attention. The 
term catarrh is derived from the Greek word aatfappc, to flow 
down ; *a*a signifying augmented action ; (See Good's Account 
of the affixes and suffixes of medical terms, in his Nosology, and 
in the first volume of the London Medical Society's Memoirs, 
2d series.) thereby denoting the defluxion or discharges from the 
head and other parts, the seat of the disease. I have formerly 
told you that catarrh and dysentery both hold an improper place 



CATARRH. 495 

in Dr. Cullen's Nosology. Dysentery, as I have already shown 
you, is not only a febrile disease, but altogether of a different cha- 
racter from those which belong to the profluvia. The least atten- 
tion, too, to the nature of the disease constituting catarrh, will also 
convince you that Dr. Cullen has very improperly separated that 
disease from the other phlegmasia?; indeed Dr. Cullen himself ad- 
mits, in his note, that although he has placed catarrh and dysen- 
tery among the profluvia, that catarrh, from the fever attending 
it, and the phlogistic diathesis which it exhibits, is most nearly 
allied to the phlegmasia?. "Catarrhus quidem pyrexia et diathesi 
phlogistica, phlegmasiis maxime affinis est." Definition — Pyrexia 
saepe contagiosa; muci ex glandulis membrana? narium,* faucium 
vel bronchiarum excretio acuta; saltern hujus excretionis moli- 
mina. This is certainly a bad definition; it exhibits nothing of 
the inflammatory character of the disease; in my opinion it should 
be defined an inflammation, not enlargement, as I have through 
mistake designated it in my Nosology, of the mucous membrane 
lining the nares, fauces, trachea, and bronchia?; attended in the be- 
ginning with a diminished, but terminating in an increased and 
morbid, excretion from these surfaces. Sometimes it affects chiefly 
the head, but not the throat or lungs, and produces a sharp acrid 
discharge from the membrane lining the nares. This form of the 
disease Hippocrates called coryza, thereby denoting the sharp 
defluxion which takes place from the head, and which defluxion 
he also supposed, by falling upon the other parts of the throat, 
fauces, &c, to. create the inflammation that affects those parts. In 
some instances it affects the head, producing a great sense of weight 
and fulness; in that case the Roman physicians gave it the name 
of gravedo. In some instances it affects the nose with great vio- 
lence, ending in ulceration ; it is then called, from the offensive 
character of the disease, ozena, from o^y, stench, or o£«, to stink. 
In other instances it fastens itself principally on the tonsils, be- 
ing then called cynanche tonsillaris. In others the larynx or 

* The membrane called Schneider's membrane ; so called from the person who 
first described it, and who has written six quartos on catarrhal inflammation of 
this membrane. He, as well as Hoffman, is disposed to extend the term catarrh 
to the mucous glands in general. Parr also extends it still further, considering 
even affections of the mucous membranes of the" bladder, intestines, urethra, &c. 
under the same genus, taking in all the mucous tissues of the French. 



496 LECTURE XLI. 

trachea becomes the seat of its violence, forming cynanche laryn- 
gea or cynanche trachealis. In others again the surface of the 
lungs or bronchiae suffer most, constituting bronchitis, as Dr. 
Bedham calls it, which is no more nor less the peripneumonia 
notha of Sydenham, the catarrhus bronchialis. The old couplet 
limits catarrh as follows, 

" Si fluit ad pectus dicatur rheuma catarrhus ; 
Ad fauces, bronchus; ad nares esto coryza." 

It may be observed, that whenever it is thus confined to any one 
particular part, it is much more violent than when the inflamma- 
tion is more diffused over a greater surface of the membranes 
mentioned, and whatever may be the part affected, whether the 
head, tonsils, trachea, or bronchise, and the inflammation in that 
case is not always confined merely to the mucous membranes, but 
frequently extends to the dense membranes beneath, and to the 
very substance of the organ affected; the symptoms too are in all 
respects more violent when thus circumscribed to a part or to a 
particular organ, but depending also very much on the texture 
and importance or degree of vitality of the part thus affected. 
Hence, Celsus was led to remark on this subject, that this disease, 
when it affects the nostrils, is mild; when it falls upon the fauces, 
it is worse, but still worse when it attacks the lungs. " Distillat 
autem humor de capite interdum in nares, quod lene est; inter- 
dum in fauces quod pejus est ; interdum etiam in pulmonem, quod 
pessimum est." (Lib. iv. cap. 4.) The tendency to those differ- 
ent forms in which catarrhous affections invade the system, is very 
much governed by peculiar circumstances ; it depends on the pre- 
disposition derived from former attacks, whether it be in the form of 
hives, affection of the tonsils, or a peripneumony. The sensibility 
of the trachea, from time of life, and the inability in infancy to 
excrete or to eject the excreted matter, may lead to the former 
disease or croup ; for we find that disease chiefly confined to in- 
fancy, but not exclusively, for adults in some cases are the subjects 
of it ; and in some instances, says Huxham, even the famous epi- 
demic contagious catarrh shewed itself as a pleurisy or peripneu- 
mony; so various are the forms which the same disease shall as- 
sume, depending on peculiarities of constitution, time of life, the 



CATARRH. 497 

sensibilities of particular parts of the body, and other circum- 
stances. But catarrh, as it ordinarily appears, comes on with the 
usual symptoms that announce phlegmasia? in general, with more 
or less of chilliness and other irritations of the nervous system ; 
and such local affections as arise from the stricture of the excre- 
tions of the part, the more immediate seat of the disease. Besides 
the sense of coldness, the person so attacked is sensible of a degree 
of fulness about the nose, the eyes, the forehead, and the fauces, 
with more or less of dryness about those parts ; this check to their 
secretions is also frequently attended with an unusual propensity 
to sneeze, and the voice too becomes changed in its tone, exhibit- 
ing a degree of roughness or hoarseness. With these symptoms 
there is also a slight irritation about the throat and trachea, and 
more or less cough, but which is dry, and in the commencement 
attended with very little pain or soreness. The eyes also manifest 
the irritation; their secretions are restrained, and there is a sense 
of stiffness in their movements, and sometimes the vessels of the 
adnata very early exhibit a degree of turgescence resembling in- 
flammation, and in a short time the whole arterial system becomes 
affected with all the symptoms of continued fever — but the cha- 
racter of this fever will be varied according to the cause produ- 
cing it ; whether it proceeds from cold or from contagion, and 
which are its two great sources. When the disease proceeds from 
cold, as wet feet or sudden changes in the atmosphere, the person 
coming from a warm room into the cold external air, or from 
change of clothing, cold bathing when the body has been pre- 
viously heated ; in that case the symptoms will be those of the 
synochal form of fever, the frequent pulse, the white tongue, and 
diminished excretions generally, a disturbed state of the natural 
as well as the vital functions, and all other symptoms of the phleg- 
masise in general ; and with these, the irritations of the parts more 
immediately affected are all, in proportion to the general action of 
the system, sensibly increased in violence; the cough becomes 
more frequent and severe, pain of the head is also increased, the 
muscles of the head, the neck, the chest, the back, and the limbs, 
also are more or less affected with pain, especially upon motion, 
not unlike the irritations from rheumatism. The secretions from 
the mucous membranes are also now increased, but instead of the 
mild bland discharges ordinarily poured out in health, they are 
acrid and excoriating to all the surfaces over which they flow ; 
43 



498 LECTURE XLI. 

the eyes, the cheeks, the nose, the upper lip, the pharynx, the 
glottis, are all scalded and sore from the sharp defluxion that 
attends this stage of the disease. 

But the stricture being taken off from the different excretory 
vessels, the fever abated, and the disease yielding, these dis- 
charges from the membranes, the more immediate seat of inflam- 
mation are also changed; they become more purulent, and the 
tone of the system being afterwards restored, they return to their 
natural character, both in quality and quantity. But when the 
disease proceeds from contagion, the character of the complaint, 
both general and local, is sensibly different from the pure un- 
mixed inflammation arising from cold. Even in its attack when 
from contagion the nervous system is more violently effected, the 
chill is more severe; delirium in some cases appears almost in the 
very commencement of the disease. The eyes are more excited, 
and sensible to light, the adnata more loaded, as in the yellow fever ? 
plague, &c, the pains more acute; pregnant women are disposed to 
miscarry and flooding is sometimes fatal. (Good, vol. ii. p. 438.) 
The whole sufferings of the patient are more severe; yet, at the 
same time the arterial system appears to be less violently affected, 
the pulse is less full and frequent, and oftentimes shows manifest 
depression very early in the disease; the tongue, too, as in other 
contagious diseases, is frequently moist — instead of the white and 
furred tongue of inflammatory catarrh. This I recollect was re- 
markably the case in the influenza of 1790 — 1; and the same was 
observed in the disease as it appeared a few years since. See Dr. 
Rush's remarks on the influenza. The Doctor was then full of 
contagion, with a regard to a great number of diseases, not only 
yellow fever, dysentery, but catarrh and our consumption he con- 
sidered of this character. In his observations on catarrh, he re- 
marks that other animals did not escape. And there is a peculiar 
tendency to the typhoid form of fever. There appears to be a 
peculiar poison operating upon the system in the case of conta- 
gious catarrh, added to the suppressed excretions; and it is re- 
marked, too, that the excretions from the affected surfaces are 
more acrid in the influenza than in common cold. It is attended 
too, with greater depression of all the vital powers, especially too, 
if the system be debilitated by the usual treatment pursued in 
simple inflammatory catarrh — the exhaustion in that case is fre- 
quently very sudden and very alarming. In the treatment of the 



CATARRH. 499 

two forms of catarrh, the same distinctions must be observed. In 
the treatment of inflammatory catarrh, occasioned by cold, or by 
the sensible changes of the atmosphere, the whole treatment must 
be strictly antiphlogostic and active in proportion to the violence 
of the symptoms. In some cases, when the disease is diffused 
over the mucous membranes of the parts, eyes, fauces, throat and 
lungs, and the fever not very violent, it is oftentimes so mild that 
by confinement to the house, abstinence from customary food and 
stimuli, with the use of tepid drinks, bathing the feet in warm 
water, and perhaps some mild aperient medicine, the disease is 
removed without anything else being done; but when the febrile 
symptoms are violent, the secretions : all suppressed, general as 
well as local, the habit of body athletic, more active measures 
then become necessary. In that case venesection must be em- 
ployed to take off the general force of the circulation, and the 
determination to the inflamed parts. Emetics, active cathartics, 
salts, calomel and jalap, sudorifics, antimonials, crem. tart, and 
tart. emet. antimony, or sp. mind, with tart, antimony, Dover's 
powder; warm bathing, general, local, paying due attention to 
temperature, aided by tepid drinks, especially mucilaginous drinks 
■ — barley water and raisins, with lime juice or currant jelly, flax seed 
and honey, toast water, rice water, common tea- — these should be 
taken frequently, but in small quantities. The steam of warm 
vinegar and water, or an infusion of hops and vinegar inhaled 
every two or three hours for one quarter of an hour, from a com- 
mon teapot, Mudge's inhaler, or from an inverted funnel. Dr. 
Bard's mode was inclosing a pot inside of curtains drawn around 
the patient. But these means are seldom called for where plenti- 
ful evacuations have been made from the blood vessels. It is 
a feeble and inert practice that has led to these expedients. But 
if the soreness of the throat and chest are more severe, and 
threaten pulmonary complaints, blisters should be had recourse 
to, the antimony and calomel continued, antimonial ointment, 
with an occasional sudorific anodyne, sp. mind. §i. laud. gtt. 
xxx. and through the day, the pectoral mixture as follows, to 
soothe the cough and irritation of the throat at the same time 
from its combination with antimony to preserve the relaxation 
of the surface. The formula is as follows: sugar, spermaceti 
aa 3ij.; the yolk of an egg; Golden sulphuret of antimony 
gr. vi. ; or tartarised antimony, gr. ij.; or antimonial wine 3ij. 



500 LECTURE XLI. 

with from 3ij. or 3iij. to ?ss. of paregor. elix. or land. 3ss. water 
^viij.; M. coch. mag. every two hours; the paregoric or anti- 
mony to be increased or lessened according to circumstances. 
Caution with regard to laudanum or opium — recollect, as Dr. 
Badham happily expresses it (p. 109), that if there were no other 
objection to opium, " it interposes a veil between the disease and 
the observer, and obscures the symptoms. " But in the first stage 
there are certainly other objections; but after evacuations have been 
made, and the irritation is kept up by the sensibility of parts and 
the acrid secretions, opiates are especially beneficial. When the 
irritation is not very great, the following mucilaginous mixture 
may be administered, with the same intention, viz: mucilag gum. 
arabic, gij.; tart. emet. gr. ij.; oxym. scill 5L; elix. paregor. : ; iij.,M. 
Another pleasant combination, J£. sacch. chrystal. vel syrup 
glycirr. §i. ; gum arabic £ss.; vit. antim. §ss.; elix. paregor. 
^i.; aq. font rbj. coch. mag. every two hours. Another favour- 
ite prescription of Dr. Badham, is gr. iij. dried squills in 
powder; gr. i. calomel; gr. i. of digitalis, M. to be taken every 
night at bed time. (Badham, p. 107 ) The diet should strictly 
correspond with this antiphlogostic treatment — all stimulating 
food should be laid aside. Regimen should be strict, and tem- 
perature of the room should be about 65°. 

But in contagious catarrh, the influenza, due regard must be 
had to the peculiar character of the disease, its typhoid tendency* 
its greater violence as it regards the vital powers, the debility 
that ensues, the inaction or loaded state of the lungs, the serous 
effusion in the chest, &c. Be cautious in the use of the lancet. It 
was tried copiously in the influenza of 1782, but with unfavoura- 
ble results; also in 1790, or 1791. Be cautious also in the use of 
violent cathartics, otherwise you prostrate the powers of the sys- 
tem, which are peculiarly depressed by the poison of the disease. 
Emetics may be used in the forming stage with great advantage, 
as they of all other febrifuges, unlock the excretions. These are 
all important in the treatment of the disease when excited by 
a foreign material introduced into the system; for the same rea- 
son expectorants, sudorifics are also indicated, and early, both 
for the purpose of diminishing febrile excitement in general, 
and to divert the peculiar irritation of the disease from affect- 
ing those organs upon which it is otherwise disposed to act 
with violence, whether the membranes be the original seat of 



CATARRH. 501 

the disease, or the vital organs of the system. Dover's pow- 
der is peculiarly useful; there is no disease in which it has 
been found more useful; without it the cough continues obsti- 
nate, and aggravates the inflammation attendant upon these 
affections. When the powers of the system are sensibly impaired, 
or the typhoid tendency begins to appear, make liberal use of the 
more stimulating drinks, such as at the same time that they keep 
the excretions open preserve the general strength, as Virginia 
snake-root, the Seneka snake-root, wine whey, vinegar whey, 
&c. Suitable diet too should be directed with the view to sup- 
port the strength of the patient; and in such typhoid tendency 
vegetable nourishments, with wine, are to be preferred. Blisters, 
I may remark, in this stage and form of the disease, should be 
cautiously applied, and should be early removed, after their stimu- 
lating effects for the removal of local symptoms have been ob- 
tained. 

Such are the remarks which occur to me with regard to the 
treatment of catarrh in these two different forms. But there is 
another stage of common catarrh yet to be noticed; I mean its 
passive stage. Thus far our observations have been confined to 
the treatment of the inflammatory, or first stage of catarrh. I 
told you that when catarrh affects the head it may leave an ozena 
behind it; a soreness of the nares, and perhaps involving the 
membrane, and possibly the bones themselves in the neighbour- 
hood of the ethmoid bone and the frontal sinuses, attended with 
a purulent discharge; and such local disease, if neglected, may 
last for months, to the great annoyance of the patient and his 
friends. How is this discharge to be restrained ? If a mere laxity 
of the vessels remain, or, in case of ulceration, what are the 
means to be employed to arrest its progress and to effect a cure? 
Treat as you would any other relaxed or ulcerated surface, 
this passive state, by stimulant applications; let the patient snuff 
up into his nostrils, three or four times a day, a small quantity of 
common rum, or rum mixed with a proportion of the tincture of 
myrrh, or eau de cologne, or bay-water, or the spirits of laven- 
der, and let the nares internally and externally be freely washed 
with the same; a solution of white vitriol may also be applied in 
the same manner, or yeast, if the parts are very offensive, may 
be made use of. But it more frequently occurs that after a com- 
mon catarrh, if it has fallen upon the bronchiae, or surface of the 
43* 



502 



LECTURE XLI. 



lungs, and especially if the chest be weak, a tendency exists to 
pulmonary complaints, or the patient be far advanced in life, that 
the relaxation of the excreting vessels remains. The vessels do 
not recover their natural diameters and they are attended with 
great increase of their natural sensibility, as well as increased dis- 
charge; and with such discharge, which oftentimes appears of a 
purulent character, the whole system daily loses strength. The 
patient is considered as exhibiting the symptoms of confirmed 
pulmonary consumption; and such too it will prove if not imme- 
diately arrested. How is this form of the disease to be arrested 
or removed ? In this state of things, when you have ascertained 
by attention to the circulation, state of the tongue, skin, respira- 
tion, degree of pain on respiration, absence of hectic excerba- 
tions, that all local inflammation has been removed, and nothing 
but laxity of the vessels remains, with general debility, and per- 
haps slight attack of fever at night, followed by night sweats — the 
indication is to give tone to the system; thereby both evils, the 
increased sensibility of the lungs, and the increased discharge from 
the excretories, are removed at the same time. 

To fulfil this indication, immediately remove your patient 
from the warm air, and the confined apartment in which he has 
been shut up; for warm air to the relaxed lungs, like a warm 
poultice to an ulcer when inflammation is removed, continues the 
discharge, and renders it a perpetual issue. Gradually, then, let 
your patient be taken out into the external air; and especially 
combine the benefits of exercise with it — at first in a carriage, 
but as soon as possible, the more stimulating exercise of riding on 
horseback. In this form of consumption, Sydenham may indeed 
say it will as assuredly effect a cure as bark will remove an inter- 
mittent. Not so, I assert, when ulcerations and destruction of 
the lungs have taken place, though in some few instances they 
also have been healed. If possible, too, as in the treatment of 
hooping cough, let your patient be removed from the land to the 
sea air — a voyage, too, will also, in such case, frequently prove 
beneficial. Bitters — the bitter infusion; chamomile, anthemis 
nobilis — (but there may be abuse of it in the first as well as the 
last stage— if useful as a tonic, surely it is prejudicial when there 
is too much excitement already existing, as in the inflammatory 
stage) — horehound, marubium vulgarre; boneset, eupator. perfol; 
lichen islandicus, should also be combined. The mineral acids, 



CATARRH. 503 

gtt. xv. to gtt. xxx. three times a day. The emplastrum calidum. 
Stimulating expectorants. Lac ammoniac — how made: take of 
the gum 5ij., aq. frigid, gviij., elix. paregor. 5iij. 

Diet. — Animal food; milk; eggs, soft boiled, raw; oysters, roast- 
ed; onions; garlic; mustard; mangos; porter; table-beer; ale; wine; 
should be made moderate use of. You cannot be too cautious, 
lest inflammatory symptoms be present. In that case, you easily 
detect it by an aggravation of all the symptoms. 

Regimen. — To sleep moderately covered ; temperature of the 
room ; flannel next the skin, to prevent a renewal of the inflam- 
mation. 

CATARRHUS SENILIS. 

There is another form of catarrh, to which I request your at- 
tention. I mean the catarrh of old age, and hence very properly 
denominated catarrhus senilis. But before I enter upon this sub- 
ject, allow me to make some preliminary observations upon the 
remarkable changes which the human constitution undergoes at 
different periods of life, and which are recognised by physiolo- 
gists and physicians under the appellation of climacterics. Se- 
condly, some introductory observations on old age, and that dis- 
ease of advanced life called climacteric disease; or as denominated 
by Sir Henry Halford, in the Med. Trans. " marasmus climac- 
tericus," called marasmus in reference to the waste of flesh, and 
diminution of bulk and strength, without any manifest cause. 

The human constitution undergoes, at different periods of life, 
various and remarkable changes, which are recognised by phy- 
siologists under the appellation of climacterics. These remarkable 
epochs the Greeks considered five in number, and from the regu- 
lar gradation which they exhibit in the human system, they 
thence denominated them climacterics, deriving the term from 
the term x%ifxax, signifying gradation. They considered the se- 
venth year as the first climacteric; the twenty-first the second; 
the forty-ninth the third ; the sixty-third the fourth ; and eighty- 
one the fifth. You perceive they are regulated by the multipli- 
cation of the figures 3, 7, 9 into each other, and are afterwards 
equalled by the multiplication of the figures 3, 7, 9, into each 
other. — Three times 7 = 21; seven times 7 = 49; seven times 
9 __ 63; nine times 9 = 81. The two last they denominated 



504 LECTURE XLI. 

the grand climacterics, being those in which the life of man was 
supposed to have consummated itself, and beyond which nothing 
was to be done but to make preparation for the grave. In some 
instances, the changes referred to have been productive of favour- 
able issue to the system ; but for the most part, they are in them- 
selves morbid, or are introductory to the formation of diseases. 
This is so frequently the case, that Sir Henry Halford has ac- 
cordingly considered them as constituting disease, which he hence 
calls marasmus climactericus. The same appellation has been 
adopted by that learned nosologist, Dr. John Mason Good. (See 
vol. ii. p. 721.) It is true, that in advanced life, even after those 
periods denominated the grand climacterics have arrived, wonder- 
ful and salutary changes have taken place ; a most extraordinary 
invigoration of the powers of the body and mind has occasionally 
shown itself. Persons who had lost the sense of hearing twenty 
years, have been known suddenly to recover it. Others have, as 
unexpectedly, recovered their lost vision, and were afterwards 
enabled to see accurately without the aid of glasses. Others, under 
this new impulse given to the constitution, have undergone a 
second dentition, and have recovered even new and entire sets of 
teeth, and in the place, too, of those that had been gradually lost 
through life. And, according to Forestus, the hair has known a 
similar regeneration. This last fact is less surprising, as we 
know the hair possesses the properties of a vegetable, as well as 
an animal nature, to grow, and change colour even after death. 

But at this advanced period of life, we more commonly see 
changes less favourable, and which prove injurious and destruc- 
tive of the powers of the constitution. At this time the strength, 
the spirits, the appetite, digestion, the passions, sleep, and indeed 
most of the functions of body and mind usually manifest declen- 
sion. In women it is remarked by some writers that these 
changes are of less frequent occurrence and less manifest than in 
men. So says Sir Henry Halford, who ascribes the fact to the 
greater exposure of men than women. This I believe, is not the 
true cause; another explanation occurs to me as much more satis- 
factory, viz: that the accumulation of blood in the female habit, 
by the cessation of the menses and the consequent excitement 
which it imparts to the system, renders women less likely to ex- 
perience this sudden expenditure of the powers of life. The ex- 
posure, however, of men to a check of the functions of the surface 



CATARRH. 505 

of the body and their less temperate habits, I believe have con- 
siderable agency in the production of the diseases of old age. 
Among the more prominent of this class of diseases is the one 
now under consideration. The catarrh of old age, or catarrhus 
senilis. 



HISTORY OF THE DISEASE. 

1st. With regard to the history of this disease, I remark first, that 
it is more especially peculiar to advanced life, and for the most 
part, makes its first appearance without any apparent exciting 
cause. 

2d. It occurs with most violence in those of the nervous tem- 
perament; and where such sensibility exists in a remarkable de- 
gree, it also appears at a much earlier period of life than in those 
of a different temperament. 

3d. It appears also with most violence and comes on earlier in 
those of a feeble, delicate constitution, whether naturally so, or 
induced by great mental exertion, by bodily labour, by intempe- 
rance, or by disease. The intemperate, if not cut off by more 
acute diseases, are sure, like Lord Ogilvie, in the play, to mani- 
fest this evidence of debauchery and premature old age. Recol- 
lect while the old gentleman was boasting of his vigour, he was 
interrupted by what he called his damned cough; this exposes 
him upon all occasions. 

4th. It attacks those with most severity, who are predisposed 
to pulmonary complaints, or who have an irritable state of the 
lungs from previous attacks of disease in those organs, such as 
hemoptysis, catarrh, pleurisy, peripneumony, &c, induced by 
this predisposition, the consequence of an attack of hemoptoe in 
early life. It appeared early in the case of Dr Rush. In his letters 
written many years before his death, he speaks of his catarrhus 
senilis as the only exception to his enjoyment of perfect health. 

5th. Debauchery also early induces this irritatable state of the 
lungs. A very remarkable instance of this local affection of the 
chest occurred a few years since in a gentleman of the city of 
New York — a sedentary life, chiefly spent at the card table, with 
loss of sleep, followed by an impaired state of the digestive or- 
gans produced this disease in the gentleman referred to, 
in a very remarkable degree, and at a much earlier period of 



506 LECTURE XLI. 

life than otherwise would have been expected. Again, it is to 
be observed that there are circumstances which in a peculiar man- 
ner prevent the occurrence of this disease. Those of a sanguine 
temperament, of an athletic frame of body, a well formed chest ? 
whose occupations or pursuits have led them to great exertion in 
the open air, are frequently exempt from this evidence of age 
until they have arrived at a very advanced period of life. 2d. 
The inhabitants of a warm climate are usually exempt from 
this attendant upon old age. 3d. In like manner those who are 
in the habit of using the warm bath, usually escape these irrita- 
tions of the chest to a very advanced period of life. We see 
this exemplified in a remarkable manner, in the south of Europe, 
particularly among the French and Italians, and among the nations 
of the east. 

A Frenchman, accordingly, who is a sort of amphibious animal, 
half his time in a warm bath, is toujours gai, toujours garcon 
keeps his vigour to the last, burns his candle to the very socket* 

The first symptoms of catarrhus senilis show themselves at the 
approach of cold weather; and to the change of seasons the dis- 
ease is usually ascribed as the exciting cause, being considered as 
the commencement of an ordinary catarrh to which it certainly 
bears great resemblance; doubtless the cool weather of autumn 
has its agency, for in summer the disease undergoes a manifest 
remission. The disease also becomes first apparent in the morn- 
ing, when the cough is the most troublesome and dry, the expec- 
toration being obtained with great difficulty. The cough comes 
on also in paroxysms which continue many minutes, somewhat 
similar to the reiterated efforts in hooping-cough; at length, 
with great difficulty, an expectoration follows of an adhesive sharp 
phlegm; more or less of a similar acrid rheum takes place at the 
same time, from the nose and eyes, followed by a soreness which is 
apt to become a permanent and troublesome symptom. Probably 
sore eyes are so frequently associated with old age, as connected 
with and proceeding from a morbid state of the excretions, except 
where great vigour appears in the system. The skin, too, be- 
comes remarkably dry, and to a degree shrivelled and covered 
with dry scurf or dandrifF. 

The excretion from the bronchia? and lungs is gradually in- 
creased by the irritation and frequent returns of the cough; and 
as the body becomes enfeebled the phlegm accumulates in the 



CATARRH. 507 

cellular part of the lungs, so as in some degree to impede the due 
circulation of the blood through the pulmonary vessels, and 
thereby to interrupt the perfect decarbonization of that fluid, 
analogous to the impeded circulation through the lungs, in the 
advanced or passive stage of peripneumony. In this manner, 
too, death very unexpectedly takes place, and in feeble old age, 
without a struggle, the interchange between the blood and the 
atmosphere being suddenly cut off by the interposing mass of 
phlegm that is accumulated. Under ordinary circumstances, a 
slight degree of febrile action, the attendant upon this complaint, 
the cheek exhibits more or less of a hectic flush; and in some 
cases a livid purple appearance of the face shows itself, with a 
correspondent quantity of circulation, and heat of the surface, 
especially in the palms of the hands. An accumulation of blood 
sometimes takes place upon the brain, producing great heat, and 
sense of burning. At other times there is giddiness, and sometimes 
coma or propensity to sleep. Captain G- — d frequently complained 
of a sense of burning upon the top of the head, attended with ver- 
tigo, both of which were increased during the paroxysms of cough- 
ing, and indeed were probably created by his frequent fits of 
coughing. The chest also, shows more or less of oppression — 
sometimes exhibiting an asthmatic fulness. In one instance, this 
appeared to be the predominant symptom. The heart, too, occa- 
sionally partakes of the irritation — it becomes irregular in its ac- 
tion, owing to the interruption in the pulmonary circulation. 
When these irritations of the brain, and whole system appear, 
there is also more or less disturbance of the digestive organs, 
especially loss of appetite, cardialgia, and flatulence ; and, vice 
versa, these latter symptoms are occasionally the means of in- 
ducing the catarrhal affection, and the consequent irritations of the 
brain that have been mentioned. 

But whence proceeds the disease? The remote causes have been 
already enumerated in the history of the disease; viz. a debili- 
tated habit of body, whether constitutional or acquired; the nerv- 
ous temperament; a variable climate ; debauchery and disease. 
When this catarrh appears early in life, it is generally remarked 
to appear as a consequence of most of the predisposing and ex- 
citing causes making up the foregoing enumeration. 

We are now led to ask the more important question, What is 
the proximate cause of catarrhus senilis? For upon the solution 



508 LECTURE XLI. 

of this question depends the principle upon which the physician 
is to proceed in palliating or removing the disease. I have never 
met with a satisfactory reply to this question, or a solution of the 
symptoms which have been enumerated. When we keep in view 
the facts that have been related, as it regards the subjects of the 
disease; the causes which induce it; the season of the year at 
which it commences; the variable climate in which it is of most 
frequent occurrence, we are prepared to believe that the proxi- 
mate cause, in part, exists in a general debility of the whole sys- 
tem; and an increased sensibility of the lungs, in common with 
that of the other parts of the body, the effect of such relaxation. 
The result of the debility thus induced, is that the determination 
to the surface of the body is thereby lessened; less blood flows 
to the surface; an accumulation of the fluids in the head and chest 
is the consequence. An increased fulness, therefore, of the heart 
and larger vessels will necessarily affect the head and lungs, both 
of which manifest the irritations which are attendant upon ca- 
tarrhus senilis. Are not the dryness of the skin, as well as the 
heat and other febrile symptoms, generally met with in this state 
of body, thus in part accounted for? The consequence of such 
determination is necessarily an increased excretion from the bron- 
chial, and from the pulmonary vessels, terminating upon the sur- 
face of the lungs. I now speak of the quantity of fluids, and 
those operating as such mechanically. 

But there is another source of this peculiar irritation in the 
lungs, attendant upon advanced age. I refer to the quality of the 
circulating fluids, as well as their mechanical accumulation, and 
the consequent increase of the excretions from the head and 
chest. It is a fact well known to the physiologist, that it is the 
peculiar province of the skin, as well as the kidne)^s, to separate 
from the circulating mass of fluids various saline and earthy ma- 
terials. Modern chemistry has very clearly made known to us 
the ingredients which constitute those discharges.* These being 
retained by the diminished diameter, and the obstruction and de- 
struction of many of the extreme vessels, what follows? I an- 
swer, an accumulation of those ingredients in the blood, unless 
they may be ejected from the constitution by the other outlets ; 

* See Thompson, Murray, Henry, and others. See Cooper's Observ. in the 
Portfolio, Jan. 1818. Observations on Gout and Stone, See his last Introductory 
Lecture. 



CATARRH. 509 

viz. the kidneys, the bowels, and other exhaling surfaces, includ- 
ing the extensive surface of the lungs. Not that there is a direct 
transportation of the peculiar matter that ought to be thrown off 
from the skin to the lungs, but an accumulation of it in the whole 
circulating mass. Thence more of it necessarily shows itself in 
those discharges passing off by the other excretions, especially 
where those excretions are most abundant, as the kidneys and 
bowels; and in old age, the lungs. But do the excretions of the 
kidneys also manifest this change in the properties of the urine? 
The reply all concur in, that they do. Hence, then, we are pre- 
pared to expect the great irritation of the bladder and kidneys, 
which is so frequently met with in old age. Hence gravel and 
stone appear more frequently in advanced life. Hence the acrid 
urine, and the painful passage of it, especially in the winter sea- 
son. Hence, too, arise the earthy, or bony deposits, which take 
place in different parts of the body in advanced life, as in the 
valves of the heart, in the coronary arteries, and other parts of 
the body, as in the pineal gland, in the membranes of the brain, 
and lungs, in the pericardium, &c. (See Baillie's Morbid Anato- 
my. ) Hence, too, arises the propensity to eruptive diseases, as 
erysipelas, pemphigus senilis, (Willan's Plates, &c.) and other 
diseases of the skin, which more or less belong to old age. 

But we see an exemplification of this change in the urinary ex- 
cretion in most persons in the winter season. Every person at- 
tending to these changes, and the influence of temperature upon 
the functions of the kidneys, must have observed the clear pellu- 
cid urine that is voided in the summer season, while that of the 
same person in winter is loaded with earthy and saline materials, 
doubtless owing to the suppression of the discharge of lithic mat- 
ter that ordinarily passes through the surface of the body. (See 
Wilson on Dyspepsia and Gravel. ) I might illustrate the same 
fact by a case which has fallen under my notice in the New York 
hospital, where mercury taken to a considerable extent in syphi- 
lis became deposited in the cells of the bones, instead of being 
discharged by the emunctories of the body; this was illustrated by 
dissection, the bone being still preserved by Dr. Porcher. An ana- 
logous case is related in a late English journal. Dr. Coxe ob- 
serves the same thing occurs in the winter of life, when the func- 
tion of the skin is to a certain degree suspended, at least impaired, 
from the obliteration of many of the small vessels of the surface, 
44 



510 LECTURE XLI. 

and the obstruction of others. The question then presents itself, 
can the secretions which take place upon the extensive surface of 
the bronchia^ and lungs be free from those acrid materials which 
show themselves in the other discharges of the body, and which 
have no longer their natural outlet ? I believe not; the peculiar- 
ly acrid quality of the fluids, as well as the inordinate quantity, 
creates the irritations attendant upon tussis senilis. 

The indications to be derived from this view of the sub- 
ject are plain. 1st. To preserve the tone of the whole system, 
and thereby the secretion by the extreme vessels upon the 
surface of the body, by which the determination to the chest is 
diminished; hence appears the importance of exercise, nutritious 
and stimulating food, especially animal food with the usual con- 
diments of the table, and the moderate use of wine and other 
stimulating drinks, especially where the person may have been 
habituated to the use. Wine, therefore, is not merely to be taken 
as St. Paul recommends it, for the stomach's sake, but for the 
sake of the whole system; hence, too, the importance of bitters, 
chalybeates, and other tonics to preserve the healthy action of the 
digestive organs and of the whole system. A second indication 
is to preserve open all the other excretions of the system, that the 
discharge by the surface of the lungs may not be increased; we 
thence also infer the importance of warm dress; flannel worn 
next the surface of the body, and that frequently changed, to give 
it all the excitement which such dress occasions; hence the use of 
friction by the flesh brush. Dr. Bond, senior, was so sensible of 
the importance of this excitement of the skin, that he was as re- 
gularly curried as his horse, and thereby attained to a very ad- 
vanced age. Hence the importance of the warm bath, both as an 
emollient to the surface as well as an excitement of its numerous 
excretories; for the same reason the bowels should be kept open, 
and attention paid to the kidneys. Such are the general means 
of preventing, and indeed of removing the evils attendant upon 
this disease. A third indication is to preserve the tone of the 
lungs themselves, and thereby to lessen the morbid sensibility to 
the causes, the more immediate agents in exciting the disease; 
but these have already been fully enumerated when speaking of 
chronic catarrh. 



511 



LECTURE XLII. 



CYNANCHE TRACHEALIS, OR INFLAMMATION OF THE TRACHEA 



The subject which next falls under our attention, trachitis, is one 
of great importance: it is a disease of frequent occurrence, violent 
and rapid in its progress, and if the necessary remedies be ne- 
glected, or not early employed, like laryngitis, is generally a fa- 
tal disease. Although this complaint has been noticed by ancient 
as well as by many modern writers, as you will see by consulting 
the aphorisms of Boerhseve, (pp. 801, 802.) yet it has never 
been minutely described, or the nature of the disease understood, 
until within a very few years. Dr. Francis Home, the late pro- 
fessor of the M. Medica in the University of Edinburgh, was the 
first who investigated the seat and pathology of this disease, and 
he was also the first who pointed out its proper mode of treat- 
ment, or rather the principles upon which the case is to be con- 
ducted. Dr. Cullen, in his aecount of the disease, has nearly tran- 
scribed Dr. Home's observations on this subject. But notwith- 
standing the publication of Dr. Home, physicians generally did 
not make themselves acquainted with this complaint. When I 
was in Edinburgh in 1792-3, Dr. Hamilton, though the professor 
of midwifery and the diseases of children, did not understand its 
nature, and applied both to Dr. Post and myself, for information on 
this subject ; for in this country it is a disease of much more fre- 
quent occurrence than it is in Great Britain. We both stated to him 
very particularly the inflammatory character of the complaint, and 
the benefits arising from the antiphlogistic plan of treatment; yet 
fj 3m his late publication, on the diseases of children, it appears 
fnat he has still a lesson to learn, for he disapproves of venesection, 
and the only medicine upon which he relies for the cure is calo- 



512 LECTURE XLII. 

mel. In like manner, in the late standard work on the diseases of 
children by Underwood, you find it considered not as an inflamma- 
tory disease, but one of a spasmodic nature, and the cure to consist 
in the use of assafoetida administered in glysters. But a late pub- 
lication by Dr. Cheyne, contains certainly a very correct practical 
view of this subject, and constitutes an exception to the general 
accounts we meet with in British books. Dr. Thomas has made 
free use of Cheyne, in his chapter on this subject. In France it 
has been so fatal a disease, and was so little understood, that the 
late Emperor Buonaparte offered, some years since, a premium of 
12,000 francs for the best dissertation on this subject ; but although 
the periodical works since have been inundated with the contents 
of the various papers which were presented, they most abundantly 
show the want of correct knowledge, either of the nature of croup, 
or of its mode of treatment. Even Dr. Albers, of Bremen, who 
has written a most able paper, and who obtained one of the 
prizes, does not understand the nature of the disease ; and his 
treatment, consequently, is inert and of little import. 

The names under which this disease is described by authors are 
various. In common language it also receives different appella- 
tions: In Ireland it is called chock, or stuffing; in England and 
Scotland, croup; but more usually in this country it receives the 
name of hives, a corruption of the term heaves, which is probably 
ao called from the heaving or violent efforts of the muscles of the 
chest and abdomen, which take place in this disease during the 
process of respiration. 

Croup, according to the imperfect and lame definition given of 
it by Dr. Cullen, in his first lines, consists " in an inflammation of 
the glottis, larynx, or upper part of the trachea, whether it affects 
the membranes of these parts or the muscles adjoining." In one 
particular this definition is defective, as the disease is not confined 
to the upper portion of the trachea, but also most usually extends 
itself throughout the whole of the windpipe, even into the bron- 
chise, and to a degree over the whole surface of the lungs. The 
effusion of the lymph, or other materials, constituting the mem- 
brane, which is the effect of this disease, also very frequently ex- 
tends into the bronchia?, though of a less firm texture than that 
part of it which is found in the upper portion of the trachea. 
Some preparations in the anatomical museum of Columbia college 
show this fact. Dr. John Augustine Smith, the late professor of 



CYNANCHE TRACHEALIS. 513 

anatomy and surgery in this university, informed me, that in a 
case of croup met with by him, in which he was called upon to 
examine the parts after death, he observed the membrane to ex- 
tend as far as the bronchias could be traced by the knife. 

Conversing also on this subject with the late Dr. Bard, the late 
president of the college of physicians and surgeons of this city, 
and who had probably been more conversant with this disease than 
most practitioners, he informed me that he had commonly obser- 
ved in those cases which he had examined after death, that the 
membrane extended into the bronchia? as well as the trachea. 

Dr. Bard also remarks, that the disease is not even limited to 
the trachea and bronchia?, but that the lungs, throughout their 
whole substance, to a certain degree participate in the affection ; 
insomuch that he has seen those organs rendered so dense and 
solid, that they exhibited in their appearance a great resemblance 
to the firm and dense structure of the liver, instead of the spongy, 
loose texture which the lungs naturally present. 

The appearances upon dissection, related by Dr. Cheyne in the 
last edition of his valuable work on this subject, correspond with 
the observations made by Dr. Bard : " When the child dies after 
an illness of four or five days, there is found lining the windpipe 
a white substance, sometimes of considerable tenacity, varying in 
thickness, and somewhat in density. It arises at, or a little be- 
low the larynx, and is prolonged into the divisions of the trachea: 
and generally a quantity of a white fluid like purulent matter, 
with which they are filled, is seen working up from the lungs. 
The inner coat of the windpipe, to which the membrane is at- 
tached, is inflamed. Generally the inflammation is also discerni- 
ble along the whole course of the membrane of the bronchia?. A 
serous fluid appears to fill the cells of the interstitial substance. 
The lungs have a solid feel, from the interstitial effusion, the ful- 
ness of the blood-vessels, and the puriform fluid in the bronchial 
tubes. There is little or no recession of the lungs when the tho- 
rax is opened. There are sometimes evident marks of increased 
vascularity in the pleura pulmonalis. There is serous effusion in 
the cavity of the thorax and in the pericardium. The cavities of 
the heart are in general unusually full of blood." 

Dr. Cullen very properly observes, that croup may arise, " first 
in these parts, and continue to subsist in them alone, or it may 
come to affect these parts from the cynanche tonsillaris or malig- 
44* 



514 LECTURE XLII. 

na spreading into them." This observation was long since made 
by Dr. Cullen, and has been abundantly established by the cases 
and dissections published by Dr. Bard, whose treatise is referred 
to in the nosology of Dr. Cullen, under the head of cynanche 
maligna. (See an Inquiry into the nature, cause, and cure of the 
Angina Suffocativa, or Sore-throat Distemper: by Samuel Bard, 
M. D. Professor of Medicine in King's College, New York. 
New York, 8vo. 1771. See also American Philosophical Tran- 
sactions, vol. 1. p. 388.) Other writers, however, do not appear 
to have paid sufficient attention to this distinction. 

Some years since I was called in consultation to a case similar 
to those described in the valuable treatise of Dr. Bard. The dis- 
ease began with an inflammation of the tonsils, but was soon suc- 
ceeded by ulceration, attended with foetid breath and a foul ap- 
pearance of the parts affected. About the third day the inflam- 
mation extended into the trachea, producing the laborious respi- 
ration, and hoarse, hollow-sounding cough which characterize 
idiopathic croup; in twenty-four hours it proved fatal. The at- 
tending physician informed me, that during the first three days 
the child had not manifested any symptoms denoting croup; but, 
as in the cases recorded by Dr. Bard, they were probably induced 
by the inflammation and subsequent acrid secretion extending 
from the tonsils into the trachea. Since that time I have met 
with several instances of a similar nature succeeding to malignant 
sore-throat. Other practitioners in this city, who have had fre- 
quent opportunities of seeing croup, confirm the observation that 
this termination of cynanche maligna is not an unfrequent oc- 
currence. Dr. Bard informs me that since the publication of his 
Essay, in 1771, he has frequently observed this disease as the 
sequela of cynanche maligna. Two cases of croup supervening 
as an accessory disease in ulcerated sore-throat are also related by 
Dr. Ferriar in his valuable paper on that subject. "Though 
there were large ulcerations in the tonsils," he observes, " there 
was nothing uncommon in the symptoms till the inflammation 
extended to the trachea, when faint, shrill coughing, hissing res 
piration, and restlessness came on, which were soon followed by 
death." (See Med. Hist, and Reflec. vol. 3. p. 205.) Croup 
also, in some instances, is the attendant upon scarlatina. A case 
of this kind occurred in a child of Mr. Peter P. Goelet, of this 
city; in that case ulcers of the tonsils, which were attended with 



CYNANCHE TRACHEALIS. 515 

considerable inflammation, and an acrid offensive discharge, pre- 
ceded the symptoms of croup: but by the use of emetic medicine 
the patient was relieved of these alarming symptoms, and by the 
use of bark and yeast, which were afterwards administered, both 
internally and as a gargle, completely restored. In Mr. Cheyne's 
treatise before referred to, a case of scarlet fever is recorded which 
proved fatal, in which the membrane was actually formed as in 
croup, and was removed after death by Dr. Rollo, surgeon of the 
Woolwich hospital. (See Cheyne, p. 37.) 

In some instances, especially where ulcerations take place in 
the larynx, croup also succeeds to measles. (See Cheyne, p. 39.) 
In a case related by Dr. Cheyne, it also succeeded to the secon- 
dary fever of small pox; and by Dr. Underwood it has been 
known as the attendant upon the putrid thrush. (See Diseases of 
Children, 4th edit. vol. 1. p. 333.) Croup also, says Dr. Cheyne, 
very often supersedes a common catarrhal affection. In a singu- 
lar instance, Dr. Ferriar also observes, that he has seen pneumo- 
nic inflammation converted into a croup on the tenth day of the 
disease. (Med. Hist, and Reflec. vol. 3. p. 205.) Dr. Rush re- 
marks, '"I have seen it accompany as well as succeed the small 
pox, measles, scarlet fever, and apthous sore-throat. In the late 
Dr. Foulke it succeeded acute rheumatism. The late Dr. Sayre 
informed me he had seen it occur in a case of yellow fever in the 
year 179S." (Med. Inq. and Obs. vol. 2. p. 376. 3d edit.) 

With these facts before us, therefore, there appears to be just 
ground for dividing this disease into two species: viz. idiopathic 
and symptomatic croup: idiopathic where the disease is primarily 
and exclusively seated in the trachea, bronchia? and surface of the 
lungs; symptomatic, where it is the consequence of other pre- 
vious diseases. 

It is asserted by some writers, but denied by others, that 
cynanche trachealis is an infectious disease. 

As the cynanche maligna and scarlatina are communicated by 
contagion or infection, doubtless they may also be so in their 
consequences; and in this way croup may be transferred by those 
diseases as the vehicle of communication. The cases related by 
Von Rosenstein, (see Von Rosenstein on the Diseases of Children, 
translated by Sparmann,) in evidence of the infectious nature of 
croup, were probably cases of cynanche maligna, simiiar to those 
described by Dr. Bard. We hence see the propriety of Dr. 



516 LECTURE XLII. 

Cheyne's observation, that " when a physician has to visit more 
children than one, with a croupy affection, in a family or neigh- 
bourhood, he ought carefully to examine the state of the fauces." 
(Von Rosenstein on the Diseases of Children, p. 19.) But that 
idiopathic cynanche trachealis is infectious, I believe there can be 
no ground for supposing. I should as readily believe that an in- 
flammation of the brain or of the pleura should be thus commu- 
nicated, as an inflammation of the membrane lining the trachea; 
and I believe it may be safely asserted that the fact is otherwise. 
In the numerous families in which I have prescribed for this dis- 
ease, I have never known it to be thus communicated, either to 
the attendants upon the sick, or to other children, even though 
sleeping in the same room, and frequently in the same bed; but I 
have more than once been called in the same night to two chil- 
dren of the same family, both having been exposed to the same 
cause, and especially where there is a great predisposition to at- 
tacks of this disease, as is the case in particular families. 

It also happens that when a child has suffered one attack of 
croup, it becomes liable afterwards to repeated returns of the 
same complaint, and that too upon the application of much 
slighter causes than had induced the first invasion. The same 
observation is made of pleurisy, sore-throat, rheumatism, and 
most inflammatory complaints. I am credibly informed of a lady 
who has suffered twenty-one attacks of pleurisy. How much 
more susceptible of impressions is the sensible membrane lining 
the trachea, especially during infancy ? But happily as this sen- 
sibility diminishes by age, the returns of the disease become less 
frequent, and when children arrive at the tenth year, it is com- 
paratively of rare occurrence. 

I have never visited a child upward of twelve years of age in 
this complaint, except where it had suffered previous attacks of 
it; yet in some instances, as before remarked, adults are the sub- 
jects of this disease. In the winter of 1809, I was called to a 
lady who had lately removed to this city from the state of Vir- 
ginia. She went to bed in perfect health; she was awakened by 
coughing, attended with pain, and a sense of burning in her 
throat. These symptoms were soon followed by difficult, hoarse, 
and laboured respiration ; her husband became very much alarm- 
ed, and called upon me between twelve and one o'clock ; I found 
her in great distress, coughing almost incessantly, every inspira- 



CYNANCHE TRACHEALIS. 517 

tion being attended with the peculiar noise of croup. Her cough 
was dry, accompanied with the usual deep hollow sound, that 
characterizes this disease in infancy. I immediately bled her 
freely from the arm, gave her an antimonial emetic, and applied 
a blister to the throat. I also left directions, that if the difficulty 
of breathing should continue, to take a dose of calomel and 
James's powder, composed of five grains each, every two hours, 
and to dilute freely with warm toast-water, herb-tea, or barley- 
water, which are the drinks I usually direct in this disease. By 
these means she was relieved in a few hours. I was also in like 
manner called upon about three years ago to another lady attack- 
ed in a very similar manner, and who was relieved by the same 
means that have been enumerated in the former case. 

During the year in which I resided in Virginia, in 1790 — 1, I 
visited, with Dr. Dick, in the neighbourhood of Alexandria, a man 
dying with every symptom characteristic of this disease. Dr. 
Mitchill, the learned professor of natural history in this univer- 
sity, suffered a severe attack of croup in the spring of 1801, dur- 
ing his attendance at Washington as a member of Congress. But 
there is an instance of this disease attacking the adult, which can 
never be forgotten, as it deprived our country and the world of 
one of their most illustrious citizens, George Washington, late 
President of the United States. 

Most writers have followed Dr. Home, in representing the dis- 
ease as more particularly confined to maritime situations; but it 
is now well ascertained, that although croup is of most frequent 
occurrence on the sea coast, where the air is loaded with moist- 
ure, and the changes of weather are most sensibly experienced, 
that it is still oftentimes met with in the interior of the country. 
The publications of Dr. Rush and Dr. Currie,* of Philadelphia, 
Dr. Stearns, of the county of Albany, in the state of New York, 
and Dr. Archer, of Maryland, afford evidence of this fact, for 
they have described the disease as it appears in places very dis- 
tant from the sea. Dr. Cullen observes, that it is met with in 
inland countries as well as on the coast. Most usually it is 



* Currie's View of the Diseases most prevalent in the United States of America, 
at different seasons of the year, with an account of the most approved method of 
treating them, &c. 



518 LECTURE XLII. 

ascribed to cold as its exciting cause. It is true, it is frequently 
produced during the severe cold of winter; but as far as I have 
noted its occurrence, it appears most frequently upon the ap- 
proach of winter, and in the spring. I have also observed, that 
during severe blowing and stormy weather the cases of it are 
most numerous. During the summer season it is also produced 
by the same cause. I have frequently traced an attack of croup 
to the imprudent exposure of a child to the night air after a hot 
day, or to a stream of air to which it had been exposed in a hall 
or window. 

This disease is described by Dr. Cullen, and by most, practical 
writers, as consisting in an inflammation of the secreting mem- 
brane lining the trachea. But Dr. Millar, (Millar on Asthma 
and Hooping-cough,) Dr. Underwood, Mr. Field, (Edinburgh 
Practice of Physic, vol. i. p. 355,) and Dr. Archer, of Mary- 
land, describe two species of croup; one inflammatory, another, 
which they denominate spasmodic croup. This disease is of 
very frequent occurrence in this city; yet, although I have been 
a practitioner of medicine since 1794, and in that time have 
prescribed for many patients in this disease, I have never met 
with a single instance in which it assumed the spasmodic cha- 
racter described by those gentlemen, that is, unaccompanied by 
symptoms of local inflammation. 

Dr. Bard, whose practice has been more extensive than that of 
any other physician of this city, informs me, that from the year 
1762 to the present time, he has never met with a case of croup 
that was not attended with symptoms of inflammation. Dr. Scott, 
of New Brunswick, who has practised medicine with great repu- 
tation in the state of New Jersey, more than fifty years, makes a 
similar observation. It is true that this disease attacks the patient 
very suddenly, and that in its commencement the affection of the 
throat is frequently without pain, and is attended with very little 
fever, even during the first two or three hours after the attack; 
while the cough, peculiar noise, and labour of respiration which 
characterize croup, are very considerable, and to the friends, ac- 
quainted with the nature of the disease, and apprised of its dan- 
gerous consequences, very alarming. Most usually, however, in 
those cases in which the child is old enough to express its sensa- 
tions, there is a sense of pricking, burning, or irritation in the 
windpipe, sufficient to denote the seat of the disease ; and such is 



CYNANCHE TRACHEALIS. 519 

the sensibility of the windpipe to the impressions made upon that 
delicate organ, that the local affection, as in the first attack of 
pleurisy, is out of all proportion to the general febrile excitement 
of the system; for neither the pulse or heat of skin are much 
affected during the first two or three hours of the disease. These 
facts, and the sudden relief which the patient sometimes obtains 
from the means prescribed during the first stage of the complaint, 
have, perhaps, led the authors mentioned, to consider croup as, in 
some cases, a spasmodic disease of the windpipe; sometimes, too, 
especially when occurring in a delicate habit of body, the use of 
the common domestic remedies, viz: warm bathing and warm 
drinks, are sufficient, by the relaxation they induce in the system 
to restore the suppressed excretions, and thereby to remove the 
irritation from the part affected. But notwithstanding this happy 
termination, it does not follow that the disease is only spasmodic, 
and not inflammatory; for we frequently see catarrh, and some- 
times even incipient pleurisy, by all acknowledged to be diseases 
exclusively of an inflammatory nature, removed without having 
recourse to the more active remedies usually resorted to; but un- 
happily this disease generally attacks children of the most robust 
habit of body, and if not immediately arrested, terminates in vio- 
lent inflammation, accompanied with fever, which are only to be 
removed by the most prompt and decisive practice. In cases of 
this sort, to trust to the prescriptions ordinarily directed for the 
removal of the most violent spasmodic affections, is to do nothing; 
it is worse than nothing; for while the physician temporises, the 
child perishes. Many lives, I believe with Dr. Ferriar, " have 
been sacrificed to the imaginary powers of assafostida, or small 
repeated doses of antimonials, from unfounded theories of spas- 
modic constriction attending the disease. " (Med. Hist, and Re- 
flec. vol.lii. p. 210.) 

Dr. Cullen observes, that the antiphlogistic regimen is neces- 
sary in every stage of the disease, and that he has not found anti- 
spasmodic medicines of any use. It is, therefore, most safe for 
us to consider with Dr. Rush, that all the varieties which this dis- 
ease assumes, " are the effects of a difference only in its force or 
in its duration, " and, to continue to use the language of that ac- 
curate clinical observer, that " they all depend upon one remote 
and one proximate cause." It also fortunately happens, that the 



520 LECTURE XLII. 

practice which is found most effectual in inflammatory croup, is 
is not opposed to that which would be indicated if the disease 
were exclusively spasmodic; on the contrary, the remedies found 
most useful in counteracting inflammation, are also among the 
most powerful antispasmodics. This leads me to add some fur- 
ther remarks on the 



TREATMENT OF CROUP. 

Writers upon this subject differ as widely as they do about the 
nature or character of the disease; but none, in my opinion, ap- 
pear to have sufficiently discriminated between the different stages 
in which the remedies they severally recommend ought to be 
employed; even Dr. Cheyne's late valuable work, and which 
contains the best pathology of this disease, is in some degree de- 
fective in this respect. I have been led at the bed side to distin- 
guish three distinct stages in croup: the first may be denominated 
the forming stage of the disease; in this the affection is local; 
the irritation has not yet extended to the whole system ; the child 
even sits laughing and playing upon the lap of its mother, mani- 
festing a very unusual but morbid degree of exhilaration; its skin 
is cool and moist, its pulse not perceptibly accelerated; but its 
hoarse, hollow sounding, and frequently returning cough, its 
wheezing inspiration, its restlessness, and especially its cries after 
a fit of coughing, all denote to the physician and parent acquaint- 
ed with the disease, the consequences that will soon ensue, if ac- 
tive means be not employed to prevent the second, or febrile 
stage. In this stage the whole system partakes of the irritation; 
the pulse is frequent, the skin hot and dry, the respiration hur- 
ried, the tongue covered with the usual white fur indicative of in- 
flammation, the lips and cheeks remarkably florid, the cough fre- 
quent, but attended with a more acute sound than that of the first 
stage; every inspiration too, is attended with more uniform 
wheezing than that which appears in the first, when occasionally 
an interval occurs in which the child breathes as if in health. 
But in this second stage no such interval is perceived; the tra- 
chea, bronchia^ and lungs become so surcharged by the circulating 
fluids, that the child has not even a momentary relief from its 
oppression; and in a short time, if left to itself, especially if the 



CYNANCHE TRACHEALIS. 521 

patient be plethoric, the countenance exhibits a purple, livid 
colour, not unlike that of apoplexy, and is even attended with a 
degree of stupor, or propensity to sleep. This loaded state of the 
lungs and interruption to the free return of blood from the head I 
have frequently witnessed in this stage of croup: if the patient be 
now neglected, or the evacuations be sparing and insufficient, an 
effusion from the exhalent vessels opening into the windpipe, 
bronchise, and surface of the lungs, inevitably takes place. In 
the two former, the effused matter assumes a membranous ap- 
pearance, probably owing to the forcible passing and repassing of 
the air through those preternaturally constricted tubes; but in the 
lungs themselves it appears in the form of a viscid fluid, partly 
resembling both phlegm and pus. When this effusion has actu- 
ally taken place, the febrile symptoms sensibly abate, and some- 
times disappear altogether; the child is also apparently free from 
pain, but it suffers violent paroxysms of cough and difficult 
breathing, attended with an irregular and spasmodic respiration, 
as in asthma, or dropsy of the chest, and with similar intervals of 
ease. These paroxysms, in young children, continue but a few 
hours before dissolution. But in children arrived at eight or ten 
years of age, they frequently continue several days. A daughter 
of Gen. Morton, whom I saw in consultation, continued to strug- 
gle with those painful paroxysms at least four or five days after 
the febrile stage had terminated, and the effusion of matter, con- 
stituting the membrane, was supposed to have taken place. In 
some cases the impediment to inspiration, and the distress attend- 
ing the paroxysms are so great, that the only position in which 
the patient can respire, is with the head thrown back. In this 
situation the trachea is extended, and thereby its capacity in- 
creased, and adapted to the membrane which it encloses. In 
some instances before death, general convulsions ensue, which 
speedily terminate the sufferings of the patient. This stage, in 
which the membranous effusion takes place, I denominate the 
membranous, or purulent stage: from this advanced state of 
the disease recovery is so rare, that it is not to be expected; it 
might almost be denominated the fatal stage of croup. These 
distinctions it is, in my opinion, important for the practitioner to 
keep in view, as they lead to important conclusions in practice. 

They teach us, during the first or forming stage of this disease, 
to adopt the most active means of restoring the suppressed secre- 
45 



522 LECTURE XLII. 

tions of the trachea and surface of the lungs, and by open bowels 
and perspiration to guard against the general excitement of the 
system. For this purpose, when called to a patient labouring un- 
der the first symptoms, in which the disease appears to be confi- 
ned to the parts primarily affected, it is my practice to administer 
an emetic composed of tartarized antimony and ipecacuanha; to a 
child under two years of age, I direct from one to two grains of 
the emetic tartar, with from five to ten grains of ipecacuanha every 
fifteen minutes, until it operates to such a degree, as to induce a 
plentiful secretion from the trachea and lungs. It is surprising, 
in some instances in this disease, to see the immense quantity of 
viscid, ropy phlegm discharged by the operation of an active eme- 
tic at this period of the complaint ; but when this discharge has 
been accomplished, and the cough has become loose, which is an 
evidence of the natural secretion being restored upon the surface 
of the parts affected, we may, in most cases, consider the patient 
secure from danger. 

It is usual with many physicians, upon these occasions, to ad- 
minister large quantities of warm water to the patient, under the 
operation of an emetic: this practice, in my opinion, by washing 
the medicine out of the stomach, and diluting it, diminishes the 
nausea and general relaxation which it otherwise produces, and 
upon which its beneficial effects in a great degree depend. When 
the emetic has no other effect than to produce vomiting, I imme- 
diately direct the bowels to be emptied by the common domestic 
injection, and a dose of calomel from five to ten grains to be given, 
unless the child may be completely relieved ; for it frequently 
happens that an emetic alone, by restoring the excretions from the 
windpipe and lungs, and the other evacuations, by perspiration 
and stool, which it creates, affords immediate relief, especially if 
the physician be called early in the disease. 

The same result is thus noticed by Dr. Rush, in his excellent 
practical remarks on cynanche trachealis: 

" In the forming state of this disease, which may be easily 
known by a hoarseness, and a slight degree of stertorous cough, a 
puke of antimonial wine, tartar emetic, ipecacuanha, or oxymel of 
squills,* is for the most part an immediate cure. To be effectual, 

* As the operation of the squills is very much limited to the stomach, and does 
not produce the same general relaxing effects upon the whole system that are pro- 



CYNANCHE TRACHEALIS.. 523 

it should operate four or five times. Happily, children are seldom 
injured by a little excess in the operation of this class of medicines. 
I have prevented the formation of this disease many hundred 
times, and frequently in my own family, by means of this reme- 
dy." (See Med. Inq. and Obs. vol. 2. p. 377. 3d edition, 1809. 
Philad.) 

But it too frequently happens, that many of the common family 
prescriptions are in the first instance employed, and much valua- 
ble time lost, before the physician is called upon ; in that case, if 
the febrile symptoms have already manifested themselves, other 
remedies are indicated. In this second stage of croup, such is the 
determination of the circulating fluids to the part affected, and 
such the general febrile excitement of the system, that the most 
efficient means of diminishing the plethora of the blood vessels, 
and of diverting the irritation from the part affected, become ne- 
cessary. With this view, the patient should be bled freely, in 
proportion to its age and powers of constitution; say, for a child 
under two years, from two to four ounces; from two to six years ? 
from four to six or eight ounces, and to be repeated as the urgen- 
cy of the symptoms may require. Most writers recommend the 
blood to be taken from the jugular veins ; as I have never, even 
in the youngest children, experienced any difficulty in opening a 
vein upon the back of the hand, and of drawing a sufficient quan- 
tity of blood from that part, especially after immersing the hand 
a. short time in warm water, I have never had occasion to open a 
vein in the neck; and as the child is generally very restless in 
this disease, and there is on this account more hazard in opening 
one of the jugular veins than those on the back of the hand, I 
have uniformly preferred the latter. It is also preferable on other 
accounts: it is difficult to ascertain the quantity of blood drawn 
from the jugular; the vein cannot be so readily closed, and the 
orifice is apt to open afresh by a violent fit of coughing. I con- 
fess I read with surprise the observation of Dr. Cheyne, that it 
is difficult to procure a sufficient quantity of blood from any other 
than the jugular vein. Dr. Ferriar makes a similar remark, " that 
in the case of very young children, we must almost despair, for 
it is extremely difficult to procure any blood from them by the 

duced by antimony and ipecacuanha, and having frequently been altogether disap- 
pointed in the emetic effects of it, I have totally abandoned the use of this medi 
cine in the first stages of this disease. 



524 LECTURE XLII. 

lancet." These difficulties I have never experienced ; the vein 
on the back of the hand, even in children six weeks old, being 
always perceptible to the finger, if not to the eye. 

Although I am not an advocate for small bleedings in croup, 
let me here take occasion to express my disapprobation of the 
practice of some physicians, especially that recommended by the 
late Dr. Bayley, of this city, Dr. Ferriar, of Manchester, and Dr. 
Dick, of Alexandria. (See 3d Supplement to Dr. Barton's Med. 
and Physical Journal, for May, 1809, p. 242.) I mean that of 
bleeding the patient until fainting be induced. The relaxing 
effects of blood-letting upon the system are no doubt desirable in 
this complaint, and were probably the objects which the advocates 
of this mode of treatment had in view; but having observed, in 
some instances, very serious and permanent evils to the constitu- 
tion, occasioned by the debility which this profuse evacuation had 
produced, and knowing that even the most violent attacks of 
croup will yield to a less excessive evacuation by the lancet, 
when conjoined with other remedies, I have hitherto objected to 
this practice in the extent it has been recommended. After blood- 
letting generally some partial relief is immediately obtained; res- 
piration is less frequent; the peculiar noise of inspiration is also 
diminished ; the cough becomes more loose and yielding ; the 
skin is rendered moist, and the pulse less tense and frequent. 
But these favourable symptoms are oftentimes deceptive, and of 
short duration: the cough, laboured respiration, and heat of skin, 
are perhaps all renewed in the course of an hour. In that case the 
antimonial emetic must be immediately employed. Although the 
force of the disease may have been greatly subdued by blood-let- 
ting, the alarming symptoms so frequently return, that I am now 
in the constant practice of prescribing the emetic immediately 
after blood-letting has been performed, without waiting to ascer- 
tain the effects which the bleeding alone might produce ; if, how- 
ever, after the operation of the emetic, the symptoms still conti- 
nue violent, I usually repeat the bleeding, immerse the patient in 
a warm bath, apply a large blister to the throat, covering the la- 
rynx and trachea, and administer a cathartic of calomel, from five 
to ten grains,* repeating this medicine every two hours, until it 

* Such is the efficacy of calomel in the treatment of croup, that some practitioners 
place their chief dependence upon it in every stage of this disease, even in its most 
violent forms. Dr. Stearns, of this city, a physician of great reputation, and who 



CYNANCHE TRACHEALIS. 525 

produces some sensible effect in this respect, at the same time 
soliciting its operation upon the bowels by injections occasionally 
administered. 

These several remedies have been employed, and having failed 
completely to subdue the febrile symptoms, and to divert the irri- 
tation from the trachea and lungs, I next direct small doses of 
calomel and James' powder, from two to five grains of eaeh, to 
be given every two hours, to a child under four years of age ; but 
when sufficient evacuation from the bowels may have been pro- 
cured, I frequently prescribe the antimonial wine, or a solution of 
tartar emetic, in such doses as to excite a considerable degree of 
nausea and relaxation; with these I occasionally blend a small 
portion of laudanum, where it may be indicated either in conse- 
quence of the profuse evacuation by the bowels, or when the 
cough may be very harassing to the patient, which is sometimes 
the case when the febrile symptoms are greatly moderated; in 
other respects laudanum should be administered with great cau- 
tion in this disease. 

The physician is sometimes called upon at a late period of the 
disease, where the means which have been described have not 
been employed; or if they have been, may not have succeeded, 
and in which the third stage of the disease has become apparent. 
Respiration, as in the two preceding stages, is still laborious, ac- 
companied with the same wheezing noise upon every inspiration; 
the cough also continues violent, without the least expectoration, 
and returns in paroxysms, in which the patient is threatened with 

is said to have been singularly successful in the cure of croup, prescribes it in con- 
nection with the cerated glass of antimony, at the same time administering a de- 
coction of the seneka snake-root, (polygala senega): for a child of a year old, when 
the disease has assumed its most alarming symptoms, he directs 20 grs. of calomel 
with 8 grs. of the cerated glass of antimony ; for a child of two years of age, the 
dose is increased to 25 or 30 grs. of calomel, with a proportionate increase of anti- 
mony. This combination, Dr. Stearns observes, generally operates two or three 
times as an emetic, and as often by stool; but if the disorder continues after the 
operation of this dose, he gives the decoction of seneka, and at the expiration of 
every eight hours repeats the dose of the calomel and antimony, until the cure is 
complete. In common cases he remarks that one dose is sufficient, and that he 
has never found it necessary to give more than four. Dr. Stearns, considering croup 
to arise from a torpor in the absorbents of the trachea, and not primarily an in- 
flammatory affection, disapproves of blood-letting, " as a very hazardous remedy, 
and which ought never to be prescribed in simple cases of croup." (See Coxe'ss 
Med. Museum, vol. 5. p. 195.) 
45* 



526 LECTURE XLII. 

immediate suffocation; the countenance exhibits a blueish livid 
appearance, at the same time that the patient manifests the great- 
est anxiety and distress ; occasionally, however, it has intervals 
of ease, in which its sufferings are apparently inconsiderable; but 
these intervals are of short duration, and afford no prospect of 
relief, for the effusion before mentioned, and the consequent for- 
mation of a membranous matter lining the trachea and bronchia, 
has already taken place. In this stage of the disease, it has occa- 
sionally happened that portions of the membrane have been 
thrown off by coughing, by which the patient has happily been 
preserved. Two cases of this kind are related by Dr. Home, 
(p. 53, 54,) which have induced him to hope that "art, though 
not in the way of internal medicine, may attempt effectuating the 
same end." 

But although nearly fifty years have elapsed since the publica- 
tion of Dr. Home's treatise, in which this suggestion is contained, 
we do not learn that in a single well authenticated case the ope- 
ration of opening the trachea has been successfully performed; 
and when we recollect what has already been stated, that the dis- 
ease is not limited to the trachea, that the inflammation and effu- 
sion of matter are spread over the greater part of the surface of 
the lungs, that the membrane itself frequently extends below the 
division of the trachea, the inference is plain, that even if the 
membrane alone could be detached, it would still be doubtful how 
far the disease would be removed by the operation. In one case, 
related by Dr. Home, "part of the membrane was thrown up, 
yet the patient died." (p. 53.) But although it were certain that 
the membrane was confined to the trachea alone, such must be 
the difficulty of detaching it from its connexion, and such the 
embarrassments, from the restlessness of the child, the constant 
movement of the larynx in respiration, the discharge of blood, 
&c. that must necessarily attend an operation of this sort, that I 
should be inclined to rest the whole hopes of relief, even in this 
advanced stage of the disease, upon the use of internal medicines. 

Calomel, in small but repeated doses, squills, the syrup of on- 
ions, the seneka snake-root, ammoniac, and assafoetida, and the 
vapour of vinegar and water, are the medicines upon which I 
am inclined to place most reliance at this advanced period of 
croup. As they are a class of remedies calculated to excite the 
secretion from the lungs, without impairing the general powers 



CYNANCHE TRACHEALIS. 527 

of the system, they afford, if steadily persisted in, the best means 
of loosening and of ejecting the membranous matter, as well as 
the fluid materials effused over the surface of the lungs. 

The following case, related by Dr. Rush, of the good effects of 
calomel in the advanced stage of croup, should incite us to the 
diligent use of this remedy, even after the effusion of the matter 
constituting the membrane has been ascertained to have taken 
place. The doctor odserves, " I once attended a man from Vir- 
ginia, of the name of Bampfield, who, after an attack of this dis- 
ease, was much distressed with the stertorous breathing and cough, 
which belong to it ; I suspected both to arise from a membrane 
formed by inflammation in his trachea. This membrane I sup- 
posed to be in part detached from the trachea, from the rattling 
noise which attended his breathing. He had used many remedies 
for it to no purpose. I advised a salivation, which in less than 
three weeks perfectly cured him." (Med. Inq. and Obs. vol. 2. 
p. 380.) 

But these stimulant remedies, excepting calomel, the use of 
which, in the first stages of croup, has already been noticed, 
should, in my opinion, be confined to the third stage of this dis- 
ease. Many families of this city, and some physicians too, are 
in habits of prescribing the syrup of onions in all stages of croup, 
without discrimination. So powerful a stimulant cannot certain- 
ly be administered with safety where blood-letting and other 
means of reducing the increased excitement of the system are in- 
dicated. Dr. Archer, of Maryland, has rendered an important 
service to medicine by reviving, not introducing, (see Wood- 
ville Drinker's remedy,) into general use the polygala senega, as 
a remedy in croup. Hitherto, however, it has certainly disap- 
pointed the expectations of most practitioners, because, like the 
old woman's onions, it has been prescribed indiscriminately in 
every stage of the disease; whereas, for the very reason that it is 
so useful in exciting the vessels of the trachea and lungs to a 
powerful excretion of the materials oppressing them in the last 
.stage of croup, it is certainly a hazardous prescription when those 
organs are preternaturally excited, as they are both in the form-' 
ing and febrile stages of this disease. Lest you may not have 
seen Dr. Archer's treatise, I subjoin his formula for preparing 
and administering this medicine : he observes, 

" The decoction of the root is the manner in which I have ge- 



528 LECTURE XLII. 

nerally seen it used ; the strength must be determined by the 
physician : it must be so strong, as to act sensibly on his own 
fauces, in exciting coughing, &c. Half an ounce of the root of 
seneka, bruised and simmered in a close vessel in half a pint of 
water, until reduced to four ounces, will probably in most cases 
be sufficiently strong. A teaspoonful of this to be given every 
half hour or hour, as the urgency of the symptoms may demand; 
and during these intervals a few drops occasionally, to keep up a 
sensible action of the medicine in the fauces, until it acts as an 
emetic or cathartic ; then repeated in small quantities, and so fre- 
quently, as to keep up a constant stimulus in the mouth and 
throat." (pp. 33, 34.) " The powder," he adds, u has lately 
been used in doses of four or five grains, mixed in a little water, 
with effects equally pleasing as the decoction." 

For the same reason that stimulant remedies are thus indicated, 
blood-letting, emetics, the warm bath, and such other medicines 
as relax and debilitate the system, and which were indicated dur- 
ing the two first stages, ought in this to be prohibited ; for in this 
debilitated state of the system they not only diminish the power 
of secretion, but of ejecting the matter secreted. If circum- 
stances, however, should indicate an emetic in this stage of the 
disease, and the decoction of seneka should prove insufficient, the 
sulphate of zinc or copper is certainly preferable to that of anti- 
mony or ipecacuanha, the former being less debilitating, while 
they afford all the advantage which can be obtained from the 
mechanical operation of vomiting, and which is all that can be 
desired at this advanced period of the disease ; at this time it is 
also necessary to sustain the strength of the patient by more nu- 
tritious food than is proper in the first stages ; a cup of sago, ar- 
row root, chicken soup, or weak wine whey, are now indicated ; 
but the latter should be carefully abstained from during the in- 
flammatory stages of this disease, when the patient should be 
confined to such drinks and nourishment as are least calculated to 
excite the system. Seeing then, that so little remains to be done 
in this third stage of croup, we are taught the importance of very 
active treatment during the first and second stages of this disease. 

Candour, however, obliges me to acknowledge, that in the 
course of my practice I have lost two patients in this complaint : 
the one in the month of September, 1797, a child of Mr. Nex- 
sen j the other, in April, 1808, a child of Mr. Herman Hen- 



CYNANCHE TRACHEALIS. 529 

dricks of this city. Generally speaking, I consider croup in its 
early stage as much under the controul of the remedies which 
have been enumerated, as a pleurisy or any other inflammatory 
disease. But as Dr. Ferriar justly remarks, " if the alarming 
symptoms are not mitigated during the first six hours, the disease 
will generally prove fatal." (Med. Hist, and Reflec. vol. 3. 
p. 203.) 



530 



LECTURE XLIIL 



PERTUSSIS. 



Pertussis, or hooping-cough; or, as it is very appropriately 
denominated by Sauvages, tussis convulsiva. The term hooping- 
cough, by which it is vulgarly known, refers to the convulsive, 
long inspiration, or hoop which attends the fits of coughing in 
the advanced stage of the disease. Another name by which it 
is known, is chin, or kin cough, derived from the Saxon or Ger- 
man term "kind," a child, referring to the early age of child- 
hood in which the disease most generally occurs. The ancients, 
from its violence, called it the wild or untameable cough — by the 
Greeks it was called bex theria — by the Romans, tussis farina. 
Dr. Good, with his love of novelty as to the names of diseases, calls 
it bex convulsiva. So little has been known of hooping-cough 
among either the Greek, Roman, or Arabian writers, that we refer 
to Dr. Willis, who wrote in 1664, for the first accurate description 
of the disease. It is contained in his " Pathologia Cerebri et 
Nervosi Generis," cap. xii. Dr. Willis practised medicine in 
London, between 1650 and 1680, as a cotemporary of Sydenham 
— he delivered his views of this disease in the University of 
Oxford. 

But the most ample and complete description of it is said to be 
that published by Dr. Watt of Glasgow, in 1813, who views the 
disease as one of inflammation. 

Sauvages, judging from his practice, in which he recommends 
venesection and emetics, also takes this view of its inflammatory 
character. Huxham, too, advises the same treatment — venesec- 
tion, an emetic every evening, and a blister to the chest. Dissec- 



PERTUSSIS. 531 

tions made since, by Sir Astley Cooper, also demonstrate its in- 
flammatory nature. (See Dawson's Nosology.) 

This disease, notwithstanding all that has been written upon it, 
is constantly to be found among the daily outlets of human life. 
Although the world has had a long acquaintance with this dis- 
ease, very little appears to have been done in lessening its violence 
or its malignity. The cause of this, in my opinion, has arisen 
from the incorrect views that have been taken of the nature and 
peculiar character or proximate cause of the disease. (Badingfield, 
p. 288.) 

Judging from the place which this disease holds in the system- 
atic arrangement- of Dr. Cullen and others, and indeed from the 
mode of treatment which you find directed by most practical 
writers, you would suppose hooping-cough to be exclusively a 
disease of the nervous system. Indeed, as you have already 
seen, Dr. Cullen places it among his spasmi, which conveys both 
a very inadequate and incorrect view of this disease, as we shall 
see by attending to its symptoms, and the means which have been 
found most successful in the treatment of it. 

Dr. Cullen defines it, "morbus contagious; tussis convulsiva 
strangulans, cum inspiratione sonora iterata; ssepe vomitus;" i.e. 
a contagious disease, attended with a convulsive strangling or 
suffocating cough, which is rapidly repeated or reiterated, with a 
sonorous inspiration or hoop, and oftentimes with vomiting. 

Dr. Cullen should have added, et initio cum febre synocha, or 
at least febricula; i. e. that in the commencement, or the first 
stage, it is attended with a synochal fever, at least in a moderate 
degree; for doubtless, during the first few days of this disease, a 
febrile excitement, as in common catarrh, is very manifest. No- 
thing is more common than for the physician to be sent for in 
the very commencement of hooping-cough, and to be told that 
the child has taken a cold. (Children are most affected, but not 
always. Dr. John Gregory took it from his son James, when six 
months old.) And only by the continuance of the complaint, and 
the train of symptoms which supervenes, is it known to be hoop- 
ing-cough. Indeed, I never did see a case of hooping-cough that 
was not attended, in its first stage, with more or less of the symp- 
toms denoting synochal and catarrhal fever, attended with a de- 
gree of active inflammation, and which are usually ascribed to 
cold; but which constitute an essential part of the character of 



532 LECTURE XLIII. 

the disease, and should accordingly receive the attention of the 
physician. Dissection has frequently manifested the effects of 
inflammation ; sometimes in the glottis, larynx, trachea, bronchia?, 
lungs: the air cells filled with a purulent matter, which denotes 
necessarily a preceding inflammation. Serous accumulations some- 
times have been found in the pericardium — the effects are not 
confined here — tuberculated lungs, visceral obstructions, and en- 
larged maxillary glands, have been found to be the consequence. I 
have hence been induced to place pertussis among the phlegmasia?. 
And let me add, that by treating it as one of this class of diseases, 
you render it comparatively both a short and a mild disease. With 
the same view, I divide this complaint into two stages. In the 
first, or inflammatory stage, you find mostly the symptoms of 
common catarrh; viz. a dry cough, without any expectoration; 
or if any, the patient discharges a thin, sharp humour; the tongue 
furred, attended with thirst; a dull, watery eye; and occasion- 
ally, as in some other contagious diseases, with some degree of 
soreness; head-ache; pain of the chest; and not unfrequently a 
bleeding from the nose; extravasation of the vessels of the eyes, 
or even in some cases, hemorrhage from the lungs. At the same 
time the general symptoms of fever are present, as a dry and hot 
state of the skin, diminished excretions, and a loss of appetite or 
quickened circulation. These febrile symptoms are usually 
slight. In some cases, the disease assumes a much more violent 
character, and has proved fatal before it has run through the ordi- 
nary course; and after death, inflammation of the trachea and 
lungs, with effusion, have been found. Adhesions of the pleura 
of the lungs to that lining the ribs has also, in some instances, 
taken place early in this disease. Generally however they conti- 
nue during the first fortnight, when they abate, and give place to 
others, which are of much longer duration. After the inflamma- 
tory stage has subsided, the disease frequently continues, not only 
for weeks, but for several months — six or seven — and perhaps a 
twelvemonth. When mild, it generally lasts two or three months^ 
when severe, six or seven; and when it has nearly ceased, it has 
been revived by the slightest exposure to cold. So great is the 
sensibility which follows the disease when long protracted. 

In this second, or passive stage, the vessels of the lungs be- 
come relaxed, and the excretion from them very profuse. In this 
stage, too, the fits of coughing become more tedious, attended 



PERTUSSIS. 533 

with a spasmodic affection of the lungs, or a painful and long con- 
tinued-inspiration, called hooping, or the back draught, in Scot- 
land. Indeed the spasms in some instances, become so severe 
that they amount to a general convulsion of the whole frame. 
In some instances, delirium is produced. This is in part to 
be accounted for from the increased debility, and consequent 
sensibility of the whole system, which are both increased by 
the duration of the disease, even though the original exciting 
cause be in a great degree expended. Habit continues the fits 
of coughing. But another reason is to be given for the gene- 
ral irritation and convulsion which attend on the fits of cough- 
ing that occur in the advanced stage of the disease. It is that 
the passage of the blood through the lungs being interrupted by 
coughing when long continued, the head becomes surcharged, 
and the brain more or less affected by congestion, in some in- 
stances producing convulsions; in others hemorrhage, from the 
nose or ears, or from the lungs themselves, which has proved 
fatal; and in some cases it has terminated in hydrocephalus, in an 
apoplexy } or perhaps in permanent blindness. Five hundred are 
stated to die annually of this disease, in London — in 1822, seven 
hundred and fifty-seven deaths are recorded in the bills of mor- 
tality, exceeding the deaths by small-pox. Hooping-cough, if not 
actively treated in the first stage, in some instances ends in a chro- 
nic catarrh, in asthma, or where there is the least predisposition 
to pulmonary complaints, phthisis pulmonalis has been the con- 
sequence. Contagion constitutes the exciting cause of this dis- 
ease. It is however, very much to be aggravated by other causes 
operating at the same time as cold, exercise, either of mind or 
body, or improper diet, either as it regards quantity or quality. 
These additional means of excitement should all be carefully 
avoided when the system may be under the irritation of this 
disease. 

In the treatment of this complaint, two indications correspond- 
ing with the two stages of the disease which we have pointed out, 
present ^themselves. 1st. To restore the secretion from the 
lungs, and the general excretions of the system, which are sus- 
pended or interrupted in the first stage of this complaint, and to 
moderate the excitement of the whole system. 2d. In the second 
stage, to give tone to the system, and thereby to counteract the 
46 



534 LECTURE XLIII. 

spasm and irritation which arise from the increased sensibility of 
the lungs and of the system in general. 

The remedies for the purpose of accomplishing the first, are, 
1st. Venesection, if the inflammatory symptoms be acute, and 
the patient of a full habit of body. 2d. Purging. 3d. Blisters 
are in some instances called for. Dr. Robertson, in the January 
No. (1821) of the Lond. Med. Repository, states that of all the 
remedies he has ever employed in hooping-cough, frictions on 
the region of the stomach, with the tartarized antimonial oint- 
ment, have been the most undeviatingly useful. 4. Emetics are 
especially useful in this disease, and should be frequently re- 
peated, at least every other day, until the secretion from the lungs 
be completely restored; that is, until the expectorations be abun- 
dant and easy upon the return of the fits of coughing. In the 
mean time, too, small nauseating doses of the antimonial solution, 
or of antimonial wine, will be found useful in removing the febrile 
symptoms of the first stage of this disease. In this stage of the 
disease the sudorific anodyne, consisting of a few drops of laud, 
proportioned to the age of the child, and sp. mind, or antimonial 
wine may be given occasionally, with great benefit. Another 
external application of the same character, in hooping-cough, is 
Struve's Lotion, viz: tartarised antim. 3i-> aq. font 5ij., tinct 
cantharides gj. M. (See Paris.) With the same view, the drinks 
of the patient should be calculated to aid the secretions, and 
should be given frequently, and moderately warm ; he should also 
breathe a warm air, and frequently bathe the feet in warm water 
• — in a word, all the means that have been recommended in the 
treatment of common catarrh, should be made use of in this dis- 
ease until the surfaces are all relaxed, and the secretions re- 
stored ; for this purpose, too, the diet and regimen of the patient 
should be of the antiphlogistic kind during the first stage of hoop- 
ing-cough. Another remedy which has been lately recom- 
mended in this stage of hooping-cough, is a combination of lauda- 
num, ipecacuanha wine, and the carbonate of soda; this combi- 
nation was introduced by Dr. Pearson, and is said to be very 
efficacious in the first stage of hooping-cough, and is usually pre- 
scribed after an emetic has been given — it is composed as follows; 
Jfc. tinct. opii. gtt i. ; vin. ipecac, gtt. v. ; carbon, sod. gr. ij. ; 
mixed in sweetened water— to be repeated every four hours for 
several days. As it usually produces more or less confinement of 



PERTUSSIS. 535 

the bowels, some mild purge, such as magnesia and rhubarb, should 
occasionally be given. Dr. Pearson states that he was led to the 
use of this alkaline prescription by the sour smell of the matter 
discharged in hooping-cough. (See Med. and Chir. Trans. Art. 
3d. ) In the second stage of this disease, the patient is free from 
fever; but the fits of coughing become more severe and of a con- 
vulsive nature, with a very abundant secretion of phlegm, and 
which it is alleged by some, is remarkably acrid and irritating 
to the lungs. The object of the practitioner at this period of the 
disease is, by the use of tonics, to diminish the morbid sensibility 
of the lungs and of the whole system, and thereby to diminish 
the lax state of the excretory vessels of the lungs, and to lessen 
the discharge, analogous to the treatment advised in the passive 
stage of ulcerated surfaces, or of catarrh, or phthisis. Various re- 
medies are in use for this purpose. 

All practitioners agree in the advantage of change of air in this 
complaint, and especially in removing patients from inland situa- 
tions to the air of the sea coast. 2. In this second stage of the 
disease, exercise in the open air should be made use of daily, and 
is among the best means of restoring both the strength and appe- 
tite of the patient, both of which are sensibly impaired by the 
continuance of this complaint. 3. Stimulant and tonic medicines 
are also found beneficial in lessening the sensibility of the lungs 
to the cause of the disease, for this purpose some administer the 
tincture of bark, or the tinctura amara, others the tincture of can- 
tharides, and occasionally these combined. (See Lettson's Medical 
Memoirs. ) Practitioners have been led to this internal use of the 
cantharides by the salutary operation of blisters, particularly when 
they produce strangury; (the sulphate of quinine is a good substi- 
tute in some cases.) Some prescribe the stimulant or foetid gums, 
as the lac ammoniac, or myrrh; musk has been much used, but has 
failed often. Others again have recourse to the oil of amber, or 
Margreef's artificial musk, which is considered by some as very 
efficacious in this disease. In my opinion it has no peculiar advan- 
tages over any other tonic usually administered in this complaint. 
Margreef 's receipt is, ol. succini. (amber,) 3j. nitric acid 3iij. M. 
to stand two or three days well mixed; to be then well washed, and 
to be given dissolved m w T ater to the amount of twelve grains a 
day, beginning in small doses. Thomas directs it to be dissolved 
in alcohol, and to give it in doses of four or five gtt. three or 



536 LECTURE XLIII. 

four times a day. But in this stage of the disease, such is the 
great quantity of phlegm secreted and inundating the lungs, that 
it is with difficulty discharged_by the ordinary efforts of expec- 
toration; in this case a mild emetic, and one that does not greatly 
debilitate the system, may be occasionally administered with 
great advantage; such an emetic we possess in the antipertussis, 
or what appears to be the same medicine, the solution of white 
vitriol, as directed by Dr. Moseley, and hence called Moseley's 
solution, as follows: sulphat zinc 3iij.; coccinell. contus. gr. iij.; 
aq. bullient. ibj.; sp. lavend. 3ij- M.; from a dessert to a table- 
spoonful to be given, and repeated in ten minutes if the first 
does not operate. This should be daily given while the phlegm 
is oppressive and in great quantity. Practitioners recommend a 
variety of other remedies in this disease, but without any definite 
object in view. Arsenic is recommended hy Dr. Simmons, of 
Manchester, (see Annals of Medicine, for 1797,) who states that 
by the use of Fowler's solution he is enabled to effect a complete 
cure in the course of a fortnight; but it is to be remembered, that 
he also makes use of venesection and emetics, which are proba- 
bly more useful than the arsenic. Others again make use of the 
acetate of lead, first recommended by Dr. Forbes, of Edinburgh, 
but this is certainly a hazardous prescription, especially for chil- 
dren. The oxide of zinc, from gr.ss. to a grain, two or three 
times a day, has been employed ; the nitrate of silver also, from 
the 12th to the 8th part of a grain has been given with benefit; 
the sulphate of quinine, especially where the fits return periodi- 
cally, is useful as well as the arsenic solution. Another valuable 
external application in hooping-cough is the oleum succini, mix- 
ed with common oil, and made more stimulating by the addition 
of the oil of cloves. This combination is now sold as a quack 
medicine, under the title of Roche's embrocation for the hoop- 
ing cough; it consists of olive oil §ij.; oil succin. oil earioph aa. 
§s. M. (See Paris Pharmacologia, vol. 2, p. 305.) I have used 
it with excellent effect on a sick child. In like manner Hem- 
lock, the cicuta, conium maculatum, has been used, and is a favour- 
ite remedy with Dr. Butter, giving a grain in the course of a day 
to infants under six months, and ten grains a day to adults, grad- 
ually increasing it. I have never found benefit from it. His prac- 
tice, and his theory of this disease, are alike to be disregarded. He 
places the disease in the alimentary canal ! ! He too has been tak- 



PERTUSSIS. 537 

ing a lesson out of Broussais' book, like our New York physi- 
cians who consider croup a disease of the stomach, and prescribe 
for it the corosive sublimate — " credat Judaeus Appella, non 
ego." Hyosciamus, Belladonna and Digitalis have been made use 
of; but in the second stage of this disease such narcotic and debili- 
tating remedies should all be avoided; and we certainly have 
more efficient means of removing the more violent s)-mptoms at- 
tendant upon the first stage. Another means of exciting the system 
in the second stage of hooping-cough is by the internal and exter- 
nal use of various stimulants, particularly of the alliacese, viz. 
garlic and onions; the syrup of those articles administered inter- 
nally, and the ointment for external purposes, are certainly not 
only admissible, but are very proper in the second state of this 
disease; but in the first, they should be altogether avoided as 
too exciting to the system. Prussic acid has been lately adminis- 
tered with great success by Majendie, gtt. xx. gtt. xxx.; aq. font, 
^iiij.; sp. lavender gtt x. M.; a dessert spoonful three times a 
day, gradually increase it to ^ss. three times a day. I have made 
great use of it, and with benefit, but caution should be observed 
in the use of it; be careful too to ascertain the strength of the pre- 
paration, and whether it is fresh made or old, or has been ex- 
posed to the action of light, which ehanges its qualities and thus 
leads to deception; fatal cases from its use have occurred in 
France. Fresnoi makes use of the extract of the leaves of the Rhus 
vernix,gr. iv. of the extract dissolved in giv. of syrup; a tablespoon- 
ful every three hours to a child. The diet of the patient, in the 
chronic stage of this disease, should consist of animal food; the 
moderate use of wine, porter, milk-punch, and other means of 
invigorating the system; while in the first stage of the disease, as 
in the phlegmasia in general, it should be simple and antiphlo- 
gistic. 



46 1 



53$ 



LECTURE XLIV. 



PNEUMONIA. 



Pneumonia is well defined by Dr. Cullen, viz: "Pyrexia, 
dolor in quadam thoracis parte, respiratio difficilis, tussis." 
The symptoms of pneumonia in general, are those of the phleg- 
masise, viz: 1. In its invasion, chills of irregular duration. 2. 
The symptoms of general febrile excitement, pulse frequent, 
respiration hurried, skin hot, in some cases flushed, excretions all 
diminished, tongue dry, generally furred, with great thirst. 

Its local symptoms are, pain in the chest, more especially in 
the part the seat of the inflammation, but attended with some pe- 
culiar or diagnostic symptoms, according to the texture of the 
particular part in which the inflammation may be seated. If 
seated in dense membranous parts, as the pleura, either that lining 
the ribs, that inclosing or dividing the lungs, or that constituting 
the pericardium, it will exhibit one train of symptoms, while in- 
flammation affecting the mucous and secreting membranes of the 
bronchia? and lungs will present a less violent concourse of symp- 
toms. So again, inflammation affecting the membrane connected 
with the diaphragm, will be attended with phenomena which are 
peculiar to that form of pneumonic inflammation ; while again, the 
same inflammation, if seated in the parenchymatous or cellular 
portion, constituting the chief substance of the lungs, which is 
less sensible and more yielding than the dense and comparatively 
inelastic membranes before mentioned, will be more insidious in 
its character, and will present appearances altogether opposite 
to those which we meet with in those that have already been 
referred to. Let me here remind you of the divisions or species 



PNEUMONIA. 539 

of inflammation, as seated in different organs, viz: 1st. The 
loose cellular membrane and muscular fibre, and its corresponding 
tendency to suppuration. 2d. The mucous membrane performing 
excretion, and which, to a certain degree, moderates the violence 
of the inflammation. 3d. The inelastic dense membrane, whieh 
has no outlet. 4th. Parts highly organized by a plentiful supply 
of nerves, as the skin, stomach, intestines, uterine organs, &c. 

The different terminations of these varied forms of inflamma- 
tion, and the treatment they severally demand, according to the 
texture of the part and the cause that may be operating, will be 
fresh in your recollection. So, in like manner, we have the dif- 
ferent species of inflammation exemplified in the various forms of 
pneumonic inflammation. In pleuritis we have an example of 
inflammation seated in the dense membrane. In bronchitis or 
peripneumonia notha, we find the mucous membrane showing 
the less active grade of inflammation, wiiile in the cellular or 
parenchymatous substance of the lungs we have the tendency to 
purulent effusion; and in the more sensible organ, the diaphragm, 
we have those that point out a peculiar connexion with the brain 
and nervous system. 

Inflammation of the pleura, pericardium, and diaphragm, as con- 
trasted with that of peripneumony. We will at this time recount 
the symptoms the three first possess in common; when we come 
to carditis and diaphragmitis, their peculiarities will be then no- 
ticed. Dr. Cullen's definition is this: " Pneumonia pulsu duro 
dolore plerumque lateris pungente sub inspiratione praesertim 
acuto; decubitu in latus molesto; tussi dolentissima, initio sicca, 
postea humida ssepe cruenta." Pneumonic inflammation, when 
it affects the parts first mentioned, for the most part attacks the 
robust and full habited, those of a sanguine constitution, and fre- 
quently young children. Br. Cullen most strangely says that it 
rarely attacks those under the age of puberty. Pulse hard, 
corded, small, frequent; tongue white, furred, covered with paste 
and attended with great thirst. 

Pain acute in the part, especially upon taking a full inspi- 
ration there is some interruption and cough, countenance fre- 
quently pale, even at the attack. The extremities sometimes 
cool from the same cause, with even a sense of coldness. The secre- 
tions from the lungs and whole system diminished, the cough at- 
tended with an acute sound, great pain, the child cries, the cough 



540 LECTURE XLIV. 

is dry, harsh, and frequently repeated in the same paroxysm of 
coughing. Position frequently in pleurisy erect Sometimes 
painful on one side: sometimes on the side affected, at other 
times the opposite; there is great variety in this respect. Again, 
as in the varieties I have introduced, the inflammation some- 
times has been observed to be seated more especially in the 
mediastinum, in which case the pain extends from the sternum 
to the back between the scapulae. As this form of pneumonic 
inflammation exhibits the same general symptoms, and re- 
quires the same treatment as in common pneumonia, it is therefore 
unnecessary to be solicitous about its characteristic symptoms ; 
not so with regard to carditis and diaphragm itis: these require 
more expedition, especially carditis, and some peculiar attention 
to the affections of the nervous system attendant upon diaphrag- 
mitis. I have, therefore, assigned to carditis and diaphragmitis to 
each a distinct generic place. And in carditis such is the great 
dyspnoea attending inflammation when seated in the heart, that 
the erect posture is the only one the patient can endure. After 
this enumeration of the symptoms attending pneumonic inflam- 
mation, we cannot commit the error of Baron Haller, by con- 
founding this disease with that rheumatic affection to which the 
muscles between the ribs are liable, called bastard pleurisy; for 
as I before told you, Haller believed pleurisy to have its residence 
in the intercostal muscles ; for the membranes of the lungs he 
considered to be insensible. In such rheumatic affections, attend- 
ed with spasm, cough, fever, &c, venesection, a purge, vol. or 
camphorated liniment, a blister, will generally effect a cure in a 
very short time. Pneumonic inflammation, left to itself, generally 
in a few days runs its course and proves fatal, unless the symp- 
toms may be moderated by the remedies that may be employed, 
or by the spontaneous evacuations that sometimes take place, such 
as hemorrhage or diarrhoea. Here again we ought surely to be 
surprised at the remark of Dr. Cullen, that a diarrhoea in the com- 
mencement of pneumonia, is not a favourable symptom ; on the 
contrary, like a blood-letting, it frequently affords immediate re- 
lief. Pneumonic inflammation has various terminations; it takes 
place either in resolution or in adhesion to the pleura lining the 
ribs, and a purulent effusion constituting empyema, in which the, 
matter finds its way between the ribs, and points externally. But 
although an adhesion will most usually take place, and the matter 



PNEUMONIA. 541 

be circumscribed in the manner just mentioned, this is not always 
the case. The matter, 3dly. is in some instances effused into the 
cavity of the chest. Sometimes again, 4thly. the inflammation, 
though originally seated in the pleura, involves the cellular sub- 
stance of the lungs, as well as the membranes — i. e. a vomica or 
collection of purulent matter, is formed in the substance of the 
lungs themselves, as abscess takes place in other cellular mem- 
branes ; and if the collection be large, upon bursting, it frequently 
proves instantly fatal, entirely covering the surface of the lungs, 
and immediately suspending respiration. Sometimes fifteen or 
twenty days elapse before the collection bursts through the pari- 
etes that enclose it. But how is such vomica known to exist ? 
By the frequent chills, by the dyspnoea, cough without expecto- 
ration, a livid colour of the body, and a regularly formed hectic; 
two paroxysms in every twenty-four hours. If such collection be 
small, and the habit not scrofulous, i. e. not previously debilita- 
ted, and there be no peculiar predisposition from make of chest, 
or habit of body, to phthisis pulmonalis, it is frequently thrown 
off without any permanent injury to the constitution, analogous to 
the sudden rupture of a blood vessel in the lungs. The patient as 
readily recovers, as from the rupture of a blood vessel, or an ab- 
scess in any other part of the body, provided there be no predis- 
position to consumption ; so in some cases where abscess is pro- 
duced, it ends without permanent phthisis. (Case of Abm. 
Franklin's child; recovered by bark and vitriol, after such accu- 
mulation and discharge of matter, the result of pneumonic inflam- 
mation.) 

5. In some instances, again, the matter may be absorbed, and 
the parts remain in a sort of scirrhus state, i. e. from the union 
of many of the cells in a solid mass, as you may see illustrated by 
the dissections made by Quarin, and the indurated lungs as they 
are described by Cleghorn. 

But 6. If the collection be large, and it occurs in phthisical ha- 
bits, it most usually ends in consumption of the lungs, attended 
with hectic fever, frequent chills and spasmodic affections of the 
chest, showing'them selves in pain, cough, difficult breathing, and 
general emaciation, constituting what is vulgarly called a gallop- 
ing consumption. 

7th. In some cases a profuse discharge takes place from the sur- 
face of the lungs, without the destruction of the lungs themselves, 



542 LECTURE XLIV. 

attended with comparatively little fever, but the patient, neverthe- 
less, gradually wasting.* In such case it frequently proves a dis- 
ease of long duration. But where such predisposition to phthisis 
does not exist, and expectoration is going on without chills or 
fever, as in chronic catarrh, the patient may be frequently re- 
lieved, especially if well managed by the physician; I mean by 
suitable stimulant and tonic means, but not by relaxing the patient; 
(remember the analogy to ulcers). It is in such state of the lungs 
that the Lichen Islandicus, like the horehound, has been found 
very beneficial, and has given credit to physicians as possessing 
skill in the cure of consumption. Pneumonic inflammation, too, 
in some cases ends in sphacelus. The lower portion of the mem- 
brane covering the lungs has been found adhering to the membrane 
lining the ribs, and some parts of it sphacelated; not merely gan- 
grenous, but actually sphacelated — (facile lacerabilis). 

But when pneumonia is seated not in the dense membranes in- 
closing the lungs, or lining the ribs, but the mucous membrane 
and cells of the lungs, its symptoms differ considerably from those 
enumerated. This form of inflammation has also been well charac- 
terised by Dr. Cullen. Read his definition of peripneumonia, (No- 
sologia, vol. 2. p. — .) "Pulsu non semper duro, aliquando molli, 
dolore thoracis obtuso; respiratione perpetuo difficile, ssepe non nisi 
trunco corporis erecto exarcenda; faciei tumidse colore purpuero; 
tussi plerumque humida, ssepe cruenta." This includes the perip- 
neumonia notha of Sydenham, Huxham, and Boerhave/ and the 
bronchitis of Dr. Badham, which is a milder form of the same dis- 
ease, being confined chiefly to the mucous membrane; but, by the 
by, sometimes more dangerous, especially when it attacks the aged. 
I will just remark that the discharge of blood does not very often 
take place in the beginning. The pulse is always soft, compared 
with pleuritic inflammation. Dr. Thomas makes a singular 
ground of distinction between what he calls true and spurious 
peripneumony. He says when it arises from sizy blood ob- 
structing the vessels of the lungs, it is called true peripneumony; 
but when it proceeds from a thick viscid matter producing a 
similar effect, it is known by the name of spurious peripneumony! 
What is the meaning of this language ? The truth is, the peri- 

* See Bedingfield, p. 97. "Pus thrown from the bronchia?, yet not the slightest 
vestige of an abscess in the substance of the lungs." 



PNEUMONIA. 543 

pneumonia notha is a mere catarrhal affection confined to the 
bronchia? and secreting surface with little or no pain; the other 
involves the whole cellular substance — they are mere grades, 
however, of the same affection, though Dr. Badham thinks other- 
wise. (See Thomas, p. 136, 4th edition.) 

Peripneumony generally attacks those more advanced in life ; 
frequently the aged; not always; in some cases the young are the 
subjects of it ; especially where they are, from make of chest, or 
from some hereditary scrofulous taint, predisposed to pulmonary 
complaints; or in cases where a premature old age may have been 
induced, by intemperance, peripneumony is apt to occur, and 
usually proves fatal. In like manner, a previous attack, even in 
the young, lays the foundation of subsequent returns of the same 
form of pneumonic inflammation upon exposure to cold. In this 
disease the pulse is frequent, soft, and full; not as in pleuritis, 
corded ; not like the tenor string of a musical instrument, as de- 
scribed by Dr. Thomas. Although, in many cases, Dr. Thomas 
is an excellent compiler, it is plain he does not draw his distinc- 
tions from the bedside, in the disease now under consideration. 
The pain is less acute, and under the sternum, and more gene- 
rally diffused over the chest; not restricted to a particular spot, as 
in pleuritis. But the distress is sometimes very great, and attend- 
ed with much anxiety; the labour of respiration, and the sense of 
oppression in some cases, especially in the aged, is such, that the 
patient cannot possibly lie down or the feeling of suffocation 
ensues. 

In these cases the violent spasmodic affection of the lungs re- 
sembles the dyspnoea of asthma, and although occurring in old 
age it is only to be relieved by the means of counteracting in- 
flammation; in younger subjects, and in the ordinary attacks, 
when the patient lies down it is one of the peculiarities of this 
form of pneumonia that he lies upon the back, not upon the side. 
Dr. Kuhn observed, that he could always distinguish by pos- 
ture alone the form of pneumonia, whether it be a pleurisy or a 
peripneumony; but add to this the spasmodic wheezing in respira- 
tion, and the comparatively loose cough also attendant upon it; 
the countenance in peripneumony too is flushed, livid, purple, 
swelled, and manifesting from the want of that interchange be- 
tween the blood and the atmosphere, the expression of great 



544 LECTTTRE XLIV. 

anxiety and solicitude; the tongue is frequently moist, or slight- 
ly furred, not the white fur noticed incorrectly by Thomas! the 
expectoration is diminished, but not as in pleurisy totally sup- 
pressed ; the discharge is thin and sharp ; the skin not so hot and 
dry as in pleurisy; the urine is even turbid, not so transparent or 
high coloured as in pleuritis. The disease, therefore, is more 
insidious; its termination too is usually different and more varied 
than pleurisy; true it frequently ends by resolution; and in some 
instances, especially in young subjects, and where the cases have 
been misconceived, it has ended in abscess, and that too notwith- 
standing the partial discharge by expectoration, that so common- 
ly takes place in peripneumony; in other instances again, in an 
effusion of blood, or by serum poured into the cavity of the chest, 
or in the interstitices of the cellular substance of the lungs, as 
was the case with Dr. Charlton, (he objected to venesection and 
died in twenty-four hours.) In full habits of body; and in aged 
persons if not immediately relieved by depletion, the symptoms 
of effusion may be generally looked for in three or four days; 
they die of hydrothorax. In others again it ends in a purulent- 
like mucous secretion from the surface in the form of a chronic 
catarrh; while in others an inflation of the lungs ensues, in 
which all the small vessels are overloaded, and without any 
or very inconsiderable discharges. In this case, if the disease 
be protracted it assumes the typhoid form of fever; in young 
subjects this event is of frequent occurrence; a new accession 
of symptoms now takes place, and is occasioned by a vitiated 
state of the habit, the consequence of long continued fever, 
and probably in part from the want of a due determination of 
the blood, which is no less essentially connected with a healthy 
state of the circulating fluids than it is with life itself. In this 
new state of things the expectoration becomes changed from its 
natural state; in the early stage of the disease it was thin, now it 
becomes glassy and more or less tinged with blood; the tongue 
too shows the typhoid character; it becomes brown, the lips ex- 
hibit more or less of a similar dark colour, the excretions are all 
offensive, delirium ensues, with the usual evidences of typhus. 
A peculiarly active treatment is now called for in this advanced 
stage of the disease, to secure the safety of the patient. The 
disease now continues depending upon constitution, from seven 



PNEUMONIA. 545 

to twenty days. These are not the terminations usually of pneu- 
monia when seated in the dense membranes investing the lungs; 
in the last the symptoms are more acute, and end in suppuration 
or sphacelus, nor is that typhoid termination of peripneumony 
frequently met with in the aged and the full habited; there it ends 
by effusion in two or three days, when it proves immediately 
fatal, or in hydrothorax which soon proves so; or sometimes, 
when the attack is slight it ends in a chronic catarrh. 



CAUSES OF PNEUMONIA. 

Those predisposing to pleuritic inflammation are — 1st. The 
sanguine temperament and plethoric habit, in those remarkable for 
a vigorous state of the digestive organs; for a weak stomach liable 
to dyspepsia is rarely of the sanguine temperament. 2. A pre- 
vious attack renders the part liable to a repetition of the same 
disease. Hoffman prescribed for the same disease in the same 
person four or five times in the same season; so of hives. 
S. The season of the year predisposes to returns of pneumonia ; 
it is accordingly of frequent occurrence in wet and cold wea- 
ther, and less frequently met with in the summer season. In 
a wet and cool atmosphere, it is not unusual at any season, say 
the army physicians. 4. Peculiar situations, as the seaboard 
and islands. 5. Make of chest; hence those who are inclined 
to phthisis are very liable to pneumonic inflammation; so far, 
then, there is a hereditary predisposition in some families to 
pneumonic complaints. The restraints imposed upon the chest 
by dress, or the habit of stooping, may also be included under 
this head. 6. Scrofulous habits of body are said to be liable 
to pulmonary complaints, especially in Great Britain, where the 
climate, moisture and cold are combined with scrofula, to produce 
diseases of the chest. 7. The predisposition to peripneumony in 
particular, is in some cases the reverse of the former, not confined 
to the vigorous and the young. To the last form of pneumonic 
inflammation we find the aged, those of sedentary habits, and 
those of lax fibres combined with fulness of the vessels, peculiarly 
liable. In habits, too, debilitated by intemperance in the use of 
spirituous or fermented liquors, especially those predisposed to 
phthisis, peripneumonia is readily induced. 8. Those, too, who 
47 



546 LECTURE XLIV. 

are debilitated by previous affections of the windpipe are very 
easily acted upon by the exciting causes of pneumonic inflamma- 
mation. Mr. T. P. was, in infancy, frequently affected with 
croup; it has left great liability to pneumonic inflammation in the 
form of peripneumony. Probably these facts are to be accounted 
for by the debility which more especially shows itself in the ve- 
nous system of the chest, in the aged, and in the feeble, and thus 
produces this surcharged state of the lungs in peripneumony. 

The exciting causes are — 1. Those applications which are calcu- 
lated to diminish or check the excretions, as, (1.) Cold, exposure to 
cool air when coming out of a heated room ; or exposure to a 
stream of air; (2.) change of dress; or not adapting the dress to 
the vicissitudes of the weather. 2d. Acrid materials applied to 
the lungs, whether mechanical or chemical; as the fine dust in- 
haled from various employments. Hair-dressers, stone-cutters, 
workers in marble, scythe grinders, &c. are hence liable to pneu- 
monic inflammation, and consumption of the lungs. The fumes 
of the different acids, in like manner, produce excitement in the 
lungs which ends in inflammation. In like manner it has been 
ascribed to the noxious exhalations of Mount Vesuvius; Vivenozi, 
Besonius, and Bovillet, in his Memoirs on Epidemic Pleurisies, 
have all recorded this disease as derived from this source. (See 
Good, vol. 2. p. 358.) 3. Extraordinary exertions of the lungs 
in public speaking, especially when those exertions are made after 
long intervals; in that manner, pneumonia and hemoptysis are 
frequently induced in clergymen, by their Sunday exertions — 
their " pulpit sweats" — after remaining quietly in their studies 
during the week. In some instances, as in hypochondriacs, with 
their gorged aad distended viscera, from full feeding and sedentary 
lives, they are greatly benefited by such inordinate exertion. The 
gentlemen of the bar, who take more bodily exercise, and who are 
in^daily habits of public speaking, are by no means in a peculiar 
manner liable to pulmonary attacks ; on the contrary, a steady ex- 
ertion of the lungs is rather calculated to invigorate those organs. 
4th. Bodily exercise carried to excess, as dancing, especially in a 
heated room, with the usual accompanying excitements of wine, 
beauty, &c, exposes the lungs, in some instances, to an attack of 
this nature, especially where they may be otherwise predisposed. 



PNEUMONIA. 547 

CURE. 

The first indication after the avoidance of the remote causes, is to 
diminish the determination of the circulating fluids to the part 
affected, keeping up the irritation, the proximate cause of the 
inflammation, by evacuations from the blood-vessels, and by 
such means as will, at the same time, relax the system, and there- 
by restore the excretions in general. 

Venesection. — Formerly there was great dispute, whether the 
blood is to be drawn from the side affected or the opposite to that of 
the seat of the disease. The earlier Greeks contended for the for- 
mer, the Galenists and Arabians for the latter. The dispute rose 
so high at last that the colleges not being able to settle the point, 
referred it to the emperor Charles the IXth; but he, to the confu- 
sion of all parties, himself died of a pleurisy, before he delivered 
his judgment — his death being ascribed to the blood.being drawn 
from the wrong side. This is usually directed to be done from a 
large orifice. It is certainly proper that the orifice should be so 
large that we can take the necessary quantity of blood, to afford 
permanent relief; but it is not required that we should produce 
deliquium, except in very feeble habits, where you do not wish to 
draw much; for taking blood from a very large orifice, you fre- 
quently produce deliquium before you have taken one-third of what 
should be drawn. Eighteen or twenty ounces should be taken 
under ordinary attacks; but if the disease be a pleurisy, it is often- 
times necessary to draw thirty or thirty-six ounces. If the ori- 
fice be very large, you will not do this before you produce faint- 
ing; even then it will be proper to place your patient in an 
horizontal posture. As to the quantity to be drawn, some caution 
too, is to be exercised, according to time of life, and habit of 
body. In the athletic adult, you can scarcely take too much, or 
repeat it too frequently, until the pain is subdued, or the respira- 
tion relieved. In some infants, and one, too, at six weeks, I have 
been obliged to draw blood half a dozen times before they were 
relieved. Avoid, however, any unnecessary waste of the vital 
fluid. Be careful, too, not to be misled by the singular appearance 
of the blood drawn, for frequently this appearance is found in the 
advanced stage, and not in the first. There is nothing more de- 
ceptive. You will see this fully noticed in many authors ; as by 
Wilson. (See vol. ii. p. 235) — by Macbride, Manning, Rush, 



548 LECTURE XLIV. 

Millar in his Diseases of Great Britain, and others. Bedingfield 
too, frequently notices the fallacy of the buffy coat as a test of 
inflammation. Even in phrenitis, as well as in pneumonia, he 
found cases of the most active inflammation, without the buffy 
coat. Bailly, too, in Laryngitis. * Look at the consistence of 
the blood, especially the quantity of coagulum; the dark colour, 
too, is some evidence of the quantity in the system, and that it 
circulates less freely through the lungs. This is the case, espe- 
cially in adults — in children, the blood is generally of a bright 
florid red colour. The circulation is more active in infancy, con- 
sequently it passes more rapidly through the lungs, and its carbon 
is disengaged in proportion to the frequency of respiration. This 
circumstance accounts for the very bright red colour which even 
the venous blood exhibits in children and in youth — especially in 
the hurried circulation during inflammatory diseases. I know 
a physician who, on drawing blood, became alarmed at the florid 
colour of the fluid, and its rapid flow per saltum, and concluded 
he had opened an artery. We must also regard the period of the 
disease at which we draw blood, with some attention. In the 
case of Counsellor Sampson, bleeding was not resorted to till the 
ninth day— but he was cured by it. In a patient of Dr. Dick's 
at Alexandria, I advised venesection on the eleventh day, and he 
was cured. In the case of a black man, who had been six weeks 
ill, and in whom the symptoms had remitted, being moderated by 
spontaneous discharges, or the means that had been prescribed for 
pneumonic inflammation, the lancet was employed with success. 
Dr. Cullen's fourth day, or even his fortnight, becomes then of 
little importance, as our guide in the use of the lancet. The best 
and only rule, I believe, is to bleed while there is difficulty or 
pain upon taking a full inspiration, or it excites coughing. 

2. By cathartics. The saline are especially useful. It is a 
general rule to avoid emetics, especially in adults — in children 
they are useful — but then most beneficial after venesection and 
cathartics. A late practice, however, has been introduced in 
Italy, to treat this disease by large doses of tartarised antimony. 

Blisters — both in pleurisy and peripneumony. Sudorifics — 
antimony tart — James' powders. Use caution as to pectorals, except 
those consisting of antimony and calomel. Laudanum, or opiates 

* See Med. Trans, vol. iii. ; one of the cases had no buffy coat* 



PNEUMONIA. 549 

in any form, should be sparingly administered, except where the 
cough is very troublesome, and out of all proportion to the other 
symptoms of inflammation; or in young children, when the 
phleghm is generally swallowed, and, as in hooping-cough, pro- 
duces griping, and sometimes diarrhoea — laudanum is then neces- 
sary, and may be given in combination with spiritus mind.; 
or the Dover's powder may be used. You may also use the 
general bath, warm, not cold, as Thomas recommends; and may 
employ foot bathing, tepid fomentations, inhaling the steam of 
warm water. Here, too, digitalis, perhaps, may be well resorted to. 

DIET 

Simple, and strictly corresponding with the antiphlogistic 
course that has been advised. Mucilaginous drinks should be 
taken frequently, but in small quantities, as bran tea, rice water, 
barley water, flax-seed tea, and those not of too great consistency 
— we otherwise fill the blood vessels and counteract what we have 
been doing by our depletion. Toast water and common tea are 
also proper beverages in this state of the lungs. The acid fruits 
in water, as weak lemonade, currant jelly and water, apple water, 
are also suitable drinks, except when the patient may be in the 
use of mercury or antimony; in that case they give pain, and in 
some cases, bring on an inordinate catharsis. 

Regimen. — Pay attention to the temperature of the drinks admin- 
istered; the air of the room; the baths which may be employed; 
the quantity of bed clothing; and avoid the stimulus of company 
and business. 

The treatment of pneumonia will also be regulated by the va- 
rious terminations of the disease, when we fail by the means 
pointed out to effect resolution. When resolution takes place, 
the disease frequently ends in a copious expectoration, when all 
stricture is removed, and the various functions are restored. But 
it also, in some instances, especially when a predisposition to 
phthisis exists, leaves an obstinate chronic cough. This is to be 
immediately counteracted by the means already pointed out when 
treating of the passive state of the lungs in chronic catarrh, viz: 
by exercise in the open air, by tonics, and especially by the 
stimulant pectorals, and suitable stimulating nourishments. This 
leads me to a few observations on the treatment of peripneumony. 



47 



550 LECTURE XLIV. 

1st. As this form of inflammation occurs most generally in the 
aged and infirm, and in those debilitated by intemperance, it 
leads us to be more cautious in the use of the lancet, which some- 
times aggravates the oppression in the lungs by the debility in- 
duced. But we for the most part, have as much occasion for 
blood-letting in this form of pneumonia, as in pleuritic inflamma- 
tion, though not to the same extent. In peripneumony, too, we 
depend for relief upon expectoration more than in a pleurisy. 
In the use of cathartics therefore, we must be guarded lest we 
prostrate the system so much as to interfere with this discharge 
from the lungs. When expectoration has begun, the cathartics 
employed should be mild in their operation, lest they suspend 
that discharge which, of all others, unloads the diseased cells and 
vessels of the lungs, and removes the congestion. Sydenham 
remarked that, in the last stage of small pox, active purging inter- 
fered with the natural terminations of the disease. So in peri- 
pneumony, so also during the lochial discharge, much purging 
induces a check of those discharges, followed by an aggravation 
of the disease that may exist at the time, and in the latter case 
induces uterine congestion and inflammation. Our chief depend- 
ence in peripneumony is to restore the natural excretions, par- 
ticularly by the skin. With this view, small doses of calomel 
and James' powders, antimonial wine and laudanum, the antimo- 
nial solution, Dover's powders, or the sp. mind, are called for.* If 
the oppression is great, blisters to the chest become necessary. In- 
haling the steam of warm water, or of an infusion of hops, will also 
greatly contribute to unload the chest in this state of congestion — 
this, too, will be greatly aided by the frequent use of some mild 
diluents, taken frequently, and of a proper temperature, they act 
as fomentations to the bronchise and lungs, at the same time that 
they promote the general excretions of the system. 

In the young, after venesection, emetics are advantageously 
prescribed for the purpose of unloading the lungs of the matter 
oppressing them, as well as their general operation upon the sys- 
tem, when the inflammatory, or active stage, has been subdued, 
and symptoms of a chronic catarrh remain, especially in the aged; 
and indeed in the young sometimes great sensibility of the lungs 
frequently remains from weakness alone. It becomes necessary 

* The pectoral mixture in some cases -will be preferable. 



PNEUMONIA. 551 

to preserve the tone of the system, and to excite the lungs and 
organs concerned in expectoration by the use of appropriate sti- 
muli. The lac ammoniac, or the myrrh, the snake-root, the 
horehound, bone-set, lichen, are now indicated, and when the 
chest is free from obstruction, bitters and other tonics, adapted to 
the general system, will rapidly contribute to the recovery of the 
patient. A more stimulant nourishment, as sago, with wine, sy- 
rups, and a portion of animal food, as oysters, a soft boiled egg, 
&c. may now be allowed, and with great advantage to the sick. 
In the young, peripnuemony, like pleurisy, sometimes ends in 
abscess or a vomica; sometimes in gangrene, by hemorrlrege, by 
an effusion of serum, or it ends in typhus fever. If a peripneu- 
mony ends in the effusion of pus, constituting a vomica, or em- 
pyema, it usually does so in six or seven days, exhibiting a pecu- 
liar train of symptoms denoting such purulent effusion, viz. fre- 
quent chills, a dark purple visage, and dyspnoea, especially in the 
horizontal posture ; but the matter may not be evacuated, that is, 
the abscess may not burst, in less than fifteen or twenty days. 
The matter, when it extends to the pleura lining the ribs, and in- 
volves the muscles between the ribs, forming a tumor externally, 
calls for an operation to discharge it; in this operation care must 
be taken always to cut upon the upper portion of the rib, in order 
to avoid wounding the artery which runs in the groove at the 
lower portion of the rib. In some cases the matter is discharged 
between the lungs and ribs into the cavity; it is then usually fatal; 
but when conveyed as just mentioned, externally, the patient 
sometimes escapes. When matter has been poured out from the 
diseased parts, whether in vomica, empeyma, or from the surface, 
whether in the cavity of the chest, or externally from the surface 
of the lungs, tonics and stimulants are then to be resorted to, to 
heal the ulcerated surfaces, or phthisis is the inevitable result 
The remedies have already been enumerated under the head of 
ulcer, and in the treatment of the passive stage of common catarrh. 
Again it ends in serous effusion, or hydrothorax. If symptoms of 
irritation still remain while such effusion is going on, the means 
of moderating inflammatory action must still be employed, and 
a diet merely sufficient to sustain the system to be directed; but 
when pure debility and hydrothorax follow without febrile ex- 
citement, accompanied too as it frequently is, with anasarca and 
a general leucophlegmasia, then the active use of tonics becomes 



552 LECTURE XLIV. 

necessary; chalybeates, bitters, with the mineral acids, and astrin- 
gents, wine, &c. If the disease terminates in gangrene, nothing 
is to be done; it ends, and suddenly, in three or four days. A 
more common termination of peripneumony in the aged or the 
feeble, is in typhus, or as denominated, typhoid peripneumony; 
in such case the disease is frequently protracted to fifteen or 
twenty days continuance, depending upon the power of the con- 
stitution and time of life. This stage is evinced by impeded and 
laborious respiration; the countenance livid, with stupor, deli- 
rium, and in some cases with convulsions, which generally prove 
fatal. The cough too is dry and unyielding, and the matter ex- 
pectorated glassy and adhesive, and oftentimes tinged with blood. 
I would here, however, remark, that bloody expectoration is 
itself not an unfavourable symptom, for it relieves the lungs of the 
great congestion that exists in them. The pulse is now soft, irre- 
gular, and frequent; the skin dry and attended with the same 
pungent heat as in idiopathic typhus fever. The tongue too is 
brown as in typhus; and there are delirium, subsultus tendinum, 
shiverings,and regular exacerbations, with a hectic cheek somewhat 
similar to phthisis pulmonalis. The remedies indicated in this case 
are similar to those recommended in typhus fever and in cynanche 
maligna. Always too, attend to the general state of the system, 
and especially avoid large evacuations; among the best means to 
be employed are such as operate upon the excretions, viz: aristo- 
lochia serpentaria, the Virginia snake-root; the Poly gala senega 
3ij. to gviij. of water; calomel with opium; the vol. alkali, in 
gr.iv. or v. in bolus, every three hours; vegetable nourish- 
ments, especially such as contain a large proportion of mucilage; 
arrow-root, sago, barley, &c. and these to be given with wine, 
the quantity of which is to be adjusted to the state of the system; 
or wine may be given in the form of wine-whey ; inhaling the 
steam of vinegar and water, by Mudge's inhaler, or with closed 
curtains. By these a favourable change is generally effected in 
all the secretions of the system, by the skin and the lungs, the 
expectoration is more natural and plentiful, and the discharge 
more easily promoted; the tongue cleans, the pulse fills, and be- 
comes less frequent, the mind and the senses are improved and 
restored; now too may be given tonics, such as bitters, sulphate 
of quinine; the mineral acids, &c. may advantageously be used. 



553 



LECTURE XLV. 

DIAPHRAGMITIS AND CARDITIS. 



Diaphragmitis was anciently denominated paraphrenias, from 
rtaga, and <pmv, the mind or soul, because the diaphragm was once 
supposed to be the seat of the mind. It is well known that a very- 
intimate connexion exists between the disease of this organ, the 
stomach, the brain, and the mind. Delirium, and the risus sardoni- 
cus, are not unfrequent symptoms of the disease of this partition 
between the chest and belly, as well as of gastritis. Boerhaave 
has given a very good description of this form of pneumonic 
inflammation; but Dr. Cullen does not believe that it possesses 
any peculiarities. Indeed he most strangely denies that it pos- 
sesses any diagnostic symptoms. He ascribes those which are 
usually deemed such, merely to the greater degree of fever 
attendant upon it. 

This disease may be known — 1 st. By the greater sense of chilli- 
ness, pain following the course of the diaphragm, along the mar- 
gin of the ribs, attended with a sense of burning; add to this, a 
stricture about the praecordia, and around the false ribs, as if girt 
with a cord. 

2d. The pain extends to the loins, following the connexion of 
that muscle (the diaphragm) with the back. The respiration, too, 
is anxious, and chiefly carried on by the intercostals, so affected 
and irregular is the action of the diaphragm, the seat of the dis- 
ease. The hypochondria, too, are drawn inwards, and kept at rest. 

3d. It is especially attended with irritations of the phrenic 
nerve, showing itself in gaping, sneezing, hiccup, delirium, some- 
times convulsions, and other evidences of a general affection of 



554 LECTURE XLV. 

the nervous system. We are not, therefore, surprised at the 
ancients denominating this variety of pneumonic disease para^ 
phrenitis. 

After this view of the peculiarities of diaphragmitis, you will 
not be at a loss to recognise it when you may meet with it in 
practice. It, however, will call for your special attention. Re- 
member that Cleghorn once mistook a case of inflammation of 
the diaphragm for a common pleurisy. After death he found the 
diaphragm to be exclusively the seat of the inflammation. 

TREATMENT. 

Venesection must be used very freely. After the bowels have 
been emptied, there must be early attention to the skin, and the 
means of restoring the general excretions, such as sp. mind, and 
laudanum, and the Dover's powder. You will perceive I incul- 
cate the early use of laudanum. I also advise the liberal use of 
it in this particular form of pneumonic inflammation; but not 
omitting other general remedies that have been directed in the 
treatment of the other forms of pneumonia ; viz. the antimonial 
solution, the early use of blisters, with the same attention to diet 
and regimen that have been so frequently inculcated in the ma- 
nagement of the phlegmasia^ 

CARDITIS. 

Inflammation of the heart, or its inclosing membrane, the 
pericardium, which should in strictness of language be deno- 
minated pericarditis. That such disease exists we have abundant 
evidence, in the dissections that are recorded by Dr. Baillie, of 
London, in his Morbid Anatomy, in which you have also seen 
illustrated, the various forms of pneumonic inflammation, and its 
consequences. In some of those dissections, in cases of carditis, 
pus has been found, actually effused, among the muscular fibres 
composing the heart itself; and in the inflammation of the peri- 
cardium you also see the effusion of lymph, or gelatinous matter, 
actually constituting an additional membrane, superadded to the 
pericardium, analogous to that formed upon other membranous 
surfaces. Dr. Cullen observes that this disease has no character- 
istic symptoms — none distinguishing it from pneumonitis. Pro- 



DIAPHRAGMITIS AND CARDITIS. 555 

bably Linnaeus, for the same reason, has taken no notice of carditis 
in his arrangement. Vogel, too, is almost induced to reject all 
distinctions between this disease and ordinary pneumonia, for he 
says of it, " Cordis inflammatio fere ut in peripneumonia." I ne- 
ver saw but one case of this disease in which its characters were 
distinctly marked ; in that my attention was called to it by the 
late Dr. Richard Bayley, of this city, in 1788. It was in a Mrs. H. 
who is yet living ; she was sitting up in bed, showing great 
anxiety, oppression, and distress, like that which frequently 
attends upon peripneumonia. 

But besides this sense of oppression, the patient, in carditis, 
and still more especially where the investing membrane of the 
heart is the seat of disease, complains of acute pain in the region 
of the heart — pointing to the very seat of suffering — -this symp- 
tom was very remarkable in the case I saw. Besides these, 
the circulation was very much affected — the pulse was very rapid 
and irregular, with great palpitation, great anxiety, a constant 
effort to cough, a tendency to deliquium, and an inability to lie 
down. Such, you will perceive, are the symptoms I have called 
your attention to in my nosology. Between inflammation of the 
heart and its investing membrane, I cannot point out any distinc- 
tion, unless it be in the acuteness of the pain and the corded state of 
the artery. In some cases we know that the heart has been found 
to contain a great deal of pus after death, when the sufferings of 
the patient have been not very acute — purulent matter, too, 
without ulcer. Hewson, it is said, first noticed this fact, and 
that Hunter established it, that pus is a secretion from the in- 
flamed vessels. Morgan, of Philadelphia, was the real discoverer. 
(See his Thesis.) 

The same causes that have been enumerated when speaking of 
pneumonia, are to be considered as creating inflammation of this 
very important viscus, including wounds. The same treatment 
too, is called for; but it is to be employed with more vigour. 
The constant anxiety, oppression, palpitation, constant effort to 
cough, the inability to lie down, the rapid and irregular circula- 
tion, all call for the most active means of depletion — by copious 
venesection and other means of diminishing the force and fre- 
quency of the circulation; and if the patient be not relieved, the 
lancet and other evacuants should be repeated. 

There is, perhaps, no disease that calls for more decision and 



556 LECTITRE XLV. 

activity in our prescriptions, than the inflammation of the heart. 
What I before observed of the necessity of copious blood-letting 
upon occasions of this nature, perhaps is more peculiarly applica- 
ble in this than in any other disease of this class. Let me for a 
moment call your attention to a case of carditis recently pub- 
lished in the 2d vol. of Med. Chir. Trans, p. 61., related by Mr. 
Featherton. This was the effect of a wound of the heart. There 
was no venesection at the beginning, and gxvi. only afterwards. 
Otherwise the patient would probably have recovered. As was 
to be expected from such inert and feeble practice the poor man 
died afterward of hemorrhage. He lived from 10 P. M. the 
29th, to 11 P. M. the 31st, that is, forty-nine hours. Let us no 
longer send our youth to British seminaries for instruction in the 
art of healing. At least let them take with them the elementary 
principles that have been inculcated by Dr. Rush, and others who 
have passed their lives at the bed side of the sick; they will then 
travel with profit in Europe, for they will then witness a feeble 
inert practice, contrasted with that pursued on this side the At- 
lantic. I speak from what I have seen, from what I have fre- 
quently heard, and from what I read in the publications that daily 
come to us from Great Britain and the continent. While the 
British are publishing every thing that can detract from our 
country, we have it in our power by a simple narrative of the 
deaths, the diseases and the treatment pursued in them, as re- 
corded in the history of the distinguished men of their country, 
to publish the severest satire upon their boasted state of medical 
science that could possibly be penned. If you will read the very 
records of the last illness of Dr. Johnson, Fox, and Pitt, you will 
find the most ample evidence of the truth of this observation. 



557 



LECTURE XLVI. 



PHTHISIS PULMONALIS. 



Our attention will now be called to pulmonary consumption, 
one of the most fatal diseases to which the human body is ex- 
posed. By the term consumption, is denoted any waste of the 
system, or of the powers of life. It is usually restricted to three 
kinds, or genera. i. Phthisis pulmonalis, or pulmonary con- 
sumption, that form of it which arises from a diseased state of the 
lungs, and is usually accompanied with hectic fever. 2. Tabes, 
or emaciation attended with hectic fever, but no cough, or other 
peculiar affection of the chest; but the hectic fever arises from 
disease of some other part of the body, as forming large ab- 
scesses, &c; and 3d. Atrophia, which is occasioned either by de- 
fect of nourishment, or. excessive discharges, but without hectic 
fever. In the first the body is wasted by daily fever, by an im- 
paired state of the digestive organs, and of the functions of respi- 
ration, with excessive discharges by expectoration, by sweating, 
and diarrhoea. In the second, or tabes, the body is also wasted 
by hectic fever arising from the absorption of the matter of ab- 
scesses or ulcers in various other parts of the body, connected 
frequently with the obstruction of the maxillary glands usually 
attendant upon one of the most common causes of tabes, viz: 
scrofula. In the third, or atrophy, as its name imports, viz: 
want of nourishment, the body is not as in the two for- 
mer cases, wasted by hectic fever, nor by any organic dis- 
ease, but simply by emaciation, and that generally the effect 
of privation, or of actual abstraction of those fluids neces- 
sary to our sustenance, as large evacuations by salivation, by 
48 



558 LECTURE XLVI. 

hemorrhage, by sweat, by leucorrhcea, long suckling, ulcers, 
issues or blisters; or it may arise from a vitiated state of the hu- 
mours of the body, from bad, or want of proper nourishments, as 
in scurvy, diabetes. 

Its importance arises from its fatality. Definition. — Corporis 
emaciatio et debilitas cum tussi, febre hectica et plerurnque ex- 
pectoratione purulenta. These symptoms do not exist in every 
case. There is no emaciation in the beginning — sometimes, too, 
very little cough, when perhaps the disease in other respects has 
made some advances. Nor is there hectic fever in the com- 
mencement — even in the advanced stage it is sometimes wanting — 
even too, when the patient is wasted by hectic, there may be no 
purulent expectoration. A case is given by Fothergill of Bath, 
without hectic fever. De Haen, in his Ratio Medendi, relates 
another case. Dr. Gregory, too, remarks " that some have died 
without being hectic." Yet he makes that expectoration com- 
bined with hectic to constitute phthisis, and says he has never been 
deceived by this union. I had a case under my care without hec- 
tic fever. In other cases there will be no purulent expectoration, 
but after death, tubercles are found; that is, numerous small vomi- 
cae or collections of pus. These are solitary exceptions to the gene- 
ral character of the disease. Morton makes two species: 1. Phthi- 
sis incipiens, that is, without expectoration of pus. 2. Confirmata 
of authors. Sauvages again, divides it differently, into sicca and 
humida. This is not in every case just, because many cases of 
confirmed consumption have no expectoration, that is, it is not 
humid.* In my opinion, a better distinction will be into two 
stages, the acute and chronic; analogous to the division by Mor- 
ton, into the incipiens and confirmed, acute and chronic, or active 
and passive. These are preferable terms, as they convey a correct 
idea of the nature of the inflammation attending upon the first stage 
of phthisis, and of the termination of such inflammation in the last 
stage in which either ulceration or an excessive excretion of pus 



* Dr. Bayle's division into six species: 1. Tuberculous. 2. Granulous. 3. 
Melanosis. 4. Ulcerous. 5. Calculous. 6. Cancerous. Of 900 patients, 624 
were tuberculous, 183 granuleuse, 72 with melanosis, 14 ulcerous, 4 calculous, 3 
cancerous. His practice is feeble, though his book contains many valuable 
facts. Portal makes fourteen species, most of them drawn from the connexion 
of phthisis with other diseases. In Morton and Sauvages there is an endless 
variety. 



PHTHISIS PHLMONALIS. • 559 

takes place. For this reason I have thought proper to give it a 
place among the phlegmasia^, instead of considering it as one of 
the hemorrhages in which order it is improperly placed by Dr. 
Cullen, he admitting at the same time that it also arises from 
other causes, because it is occasionally preceded by hemorrhages, 
but which, by the by, is only one of the numerous exciting causes 
of this very fatal malady, and that not the most frequent. Good, 
too, and Dr. Duncan have adopted this arrangement, making it a 
distinct genus. (Vol. 2. p. 742.) 

The place I have assigned to phthisis in the nosological 
arrangement, I have adopted, is also calculated to lead us to more 
correct views of practice ; for it is impossible to suppose that 
either an ulcer can exist in the lungs, or a purulent excretion 
take place from the surface without previous inflammation; it 
consequently leads us to look to the causes of such inflammation, 
and thence to the means both of preventing and of removing it 
Accordingly, if we give attention to the symptoms which an- 
nounce the approach of phthisis pulmonalis, and which constitute 
its first stage, we shall find them all of a character that denote 
great irritation and inflammation, and I may add, that this train of 
symptoms is invariably present, and characterises the first stage 
of phthisis. Among- these, are, 

1st. A cough which is dry, excited upon the slightest occasion, 
thereby showing increased sensibility in the lungs. This is per- 
ceived upon the least change of air, as going from a warm to a 
cooler apartment; from the house into the open air; upon change 
of dress; exposing the body to the air upon undressing for bed, 
or upon first getting into the bed, if the sheets be not previously 
warmed. Under these circumstances the patient is attacked with 
a paroxysm of coughing, attended with a sense of soreness and 
stricture of the chest, giving a sensation of tightness as if girt 
with a cord. A similar return of coughing takes place upon 
change of posture in the morning on leaving the bed; the least 
exposure of the body to the air in this state of the lungs renews 
the paroxysm of coughing. 

2d. In other instances the disease announces its approach by 
pain — by stitches in one of the sides of the chest, or under the 
breast bone, extending through between the shoulders, or shoot- 
ing through different parts of the chest. Upon whichever side 
too, the pain is felt, the patient frequently finds some difficulty in 



360 



LECTURE XLVI. 



lying upon the side so affected. But instead of severe or acute 
pain, in other cases the patient complains of a general soreness, 
and particularly a sense of rawness upon taking a full inspira- 
tion, or perhaps is unable to dilate the lungs without pain or 
cough. 

3d. The pulse is frequent with some stricture to be perceived 
upon the artery. 

4. The excretions are more or less generally interrupted. The 
tongue is dry, attended with thirst, and frequently a desire for 
acids. The skin is hot and dry, especially a burning and dryness 
in the hands and feet, with frequent unnatural circumscribed 
glow on the cheek and lips, while at the same time the other 
less sensible parts of the face will exhibit in contrast with these 
a preternatural paleness. 

The menstruation too is diminished, and very irregular, or per- 
haps is totally suppressed; for all the excretions are more or less 
disturbed, and that in proportion to the sensibility of frame, and 
the degree of disease existing. While these again, particularly the 
menses being suppressed, produce additional irritation both in the 
lungs and in the whole system ; and not unfrequently this fulness 
of the vessels of the lungs, increased by such general suppression 
of the accustomed secretions, frequently leads to hemoptysis and 
all the symptoms attendant upon active pneumonic inflammation. 
The patient now passes restless nights, is frequently disturbed by 
dreams, and labours under more or less of general fever, which is 
particularly increased at night ; the digestive organs now become 
disturbed ; the patient loses her appetite, complains of pain in the 
region of the stomach, with flatulence, and the other evidences of 
an imperfect digestion. As chlorosis is attended or followed by the 
pain of the chest, and that pain ends in inflammation of the lungs, 
so in this disease the pain of the chest and febrile symptoms, pro- 
duce more or less derangement of the digestive organs. This 
train of symptoms continue a few weeks, for the disease being 
seated in the cellular portion of the lungs, will not announce itself 
with the violence attendant upon the more acute inflammation that 
attacks the dense membranes. Another series of symptoms now 
supervene, and which may be said to constitute the second stage 
of the disease; a degree of expectoration now begins; the patient 
upon each fit of coughing now begins to discharge some mucus, 
perhaps slightly tinged with blood. This is, in a short time, fol- 



PHTHISIS PtJLMONALIS. 561 

lowed by purulent matter, either yellow or of a greenish hue. In 
some instances this purulent matter proceeds from an actual ulcer- 
ation, or destruction of the very texture of the lungs that may 
have taken place; in this case the breath is highly offensive, but 
not so, if the matter be a secretion from the inflamed surface, the 
texture of which is not broken. But I wish you to remember that 
a purulent discharge does not necessarily proceed from an ulcera- 
ted surface; the observations of De Haen, Morgagni, and the 
cases recorded of the dissections made by Dr. Black, the House 
Surgeon of the New York Hospital, which you will see in the 
Medical Repository, establish this fact. "An expectoration of 
pus," says Mr. Bedingfield, (p. 106.) " may and often does occur 
where there is no derangement in the structure of the lungs." 
Dr. Gregory, also, (see MSS. Lect.) says, in some cases there will 
be purulent matter from mucous membranes, but no ulcer, yet the 
matter will sink ; but he also states cases in which mucus will 
sink when very viscid, and vice versa. Indeed, in a chronic catarrh 
we see actual pus poured out from the surface that has been inflam- 
ed, but not ulcerated. In asthma we see the same thing frequently 
occurring; in hooping-cough I have oftentimes witnessed the pu- 
rulent discharge. The pericardium has been found distended with 
pus, with no ulceration of the heart or its investing membrane. 
(See Seance Publique de la Faculte de Med. de Paris, p. 14S,read 
Nov. 27th, 1811.) After enteritis and dysentery, and indeed in 
dropsy, I have seen the same product of inflammation in which no 
ulceration was to be observed. The respiration now becomes hur- 
ried from the newly formed fever, for the fever now assumes a dif- 
ferent type; the circulation is now still rapid from another cause 
than that existing in the first stage; it is now kept up by the pre- 
sence of pus in the blood vessels, or as Dr. Gregory would say, by 
the inflammatory action that begets the pus; this was the Doctor's 
view of the proximate cause of hectic. These two conditions of in- 
flammatory action, and the secretion and absorption of pus, are so 
identified, that I am very well satisfied to use either expression or 
opinion. I would however observe, in order to show that inflam- 
mation in itself does not beget hectic; that were this the case you 
would find hectic in other inflammatory diseases, where no puru- 
lent discharge attends it, whereas this is not the case. Two regu- 
lar exacerbations of fever are now manifest ; one at noon, conti- 
nuing a few hours, and, if the patient remains out of bed, it 
48* 



562 LECTURE XLVI. 

terminates without that discharge from the skin that usually at- 
tends the second paroxysm, that takes place at night ; this ends 
towards morning in profuse sweats, the surface of the body being 
relaxed, probably the warmth of the bed promotes this ten- 
dency to sweat; and we may add, as the patient is more debilita- 
ted by the recurrence of the fever, the sweats become more pro- 
fuse ; the two paroxysms are also lengthened, and run into each 
other, when the patient can hardly be said to have an intermission. 
Under this exhaustion not only do we perceive a waste of the vital 
powers, but a general emaciation and loss of flesh ; the eyes are 
sunken, yet apparently larger; the extremities become thin ; the 
nails curved around the ends of the fingers; owing to the absorp- 
tion of fat that before protruded the eyes, and gave fulness to the 
extremities; the hair, too, oftentimes falls off, from want of nou- 
rishment, as after typhus fever, the small extreme vessels that 
nourish it having lost their energy. But the eyes, though they 
are thus changed, are, as in pregnancy, remarkably clear, bril- 
liant, and of a blue, white, or pearl colour; the blood vessels of 
the surface of the eye now not carrying red blood, analogous to 
the effects of pregnancy, the red vessels entirely disappearing. 
The teeth, too, are no less remarkable for their whiteness, the 
deposits on them being less considerable. The tongue also is un- 
commonly clean and moist, for the same reason. As the disease 
advances, more or less of a paralysis or diminished action of the 
absorbent system takes place, and an impaired communication be- 
tween the arteries and veins — diarrhoea is the consequence. This 
arises from two causes ; the absorbents losing their power, and 
frequently an obstruction or congestion of the glands of the me- 
sentery actually interrupting the passage of the fluids from the 
intestines to the thoracic duct, and to the blood vessels. This ex- 
cessive discharge from the bowels is a fatal symptom; not one in 
five hundred recovers from this symptom. Accompanying this 
deranged state of the digestive organs and of the intestinal canal, 
is the ulceration of the mouth and throat, showing itself in the 
form of aphthae, and which extends itself by an erythematic inflam- 
mation, throughout the intestines, sometimes producing diarrhoea, 
generally a fatal symptom in this disease. Dropsy is also an 
attendant upon the advanced stage of phthisis, as the result of the 
loss of tone in the blood vessels and absorbents ; sometimes a hy- 
drothorax shows itself, in which the patient is unable to lie down; 



PHTHISIS PULMONALIS. 563 

but most usually the distant circulating vessels and the absorbents 
of the extremities are the first affected, producing an anasarca, 
particularly of the lower extremities. This is among the most 
alarming symptoms. At length the muscular powers are so much 
impaired, that the patient is unable to expectorate; the fluid effus- 
ed upon the surface of the lungs remains and accumulates, the 
absorbents having ceased to perform their functions, and the 
patient being unable to eject it; the air passing and repassing 
through this fluid filling the bronchiae and cells of the lungs, 
produces a rattling noise; the lungs lose their sensibility. 
In this extreme of relaxation, the discharge from the vessels is 
rapidly increased, even a bloody effusion frequently takes place, 
and instantly proves fatal. In other cases, frequently returning 
spasms close the scene ; while in other instances, they calmly 
expire, without the least apparent effort or struggle, the attend- 
ants being scarcely conscious that the patient has breathed his 
last. 

Such is the progress of this merciless enemy of the human 
race, which, in the language of an eloquent writer, spares neither 
genius, youth, or beauty, but which sweeps into the grave all that 
can adorn, embellish, or illuminate society. (Clinton's Discourse.) 

What are the causes from whence this mortal disease proceeds? 

The predisposing causes are, 

1st. An hereditary vice of the constitution, such as scrofula; 
i. e. debility of system, more or less showing itself in the gland- 
ular system. This is exemplified in a remarkable manner in 
Great Britain, particularly in Scotland. This is considered one 
of the most common causes of tuberculous consumption. 

2d. An hereditary conformation of chest, with a delicate frame 
of body. One uncommonly flattened, or the chest deformed with 
a curvature of the spine. Examples of these, predisposing to 
phthisis, are of daily occurrence. A family in this city has lost 
all their children by phthisis. The parents were brought up to 
habits of great labour and exertion. They enjoyed good health, 
possessing all the vigour that active industry is calculated to se- 
cure; but the parents becoming rich, the children were indulged 
in indolence, and every luxury which life can afford, or whim or 
fashion suggest. They have all, but a single member of this 
family, fallen victims to phthisis, induced by the slightest excit- 
ing causes, operating upon a susceptible and delicate frame of 



564 LECTURE XLVI. 

body. In another family, the same disease has fallen upon the 
females, deriving a delicate frame of chest on the mother's side. 

3d. The sanguineous temperament, characterised by a thin skin, 
light hair, a brilliant complexion, great delicacy of fibre, and a 
rapid circulation to the surface. In such a state of the system, 
the vessels are easily ruptured in consequence of feeble resistance. 
They are readily, too, affected by cold, and the other exciting 
causes, which are calculated to check the excretions of the sys- 
tem. 

4th. Debility and its attendant, an excessive sensibility of sys- 
tem. Hence it occurs more frequently among females — hence, too, 
in particular families, in which that state of constitution prevails. 
The debility, too, occasioned by immoderate evacuations, as long 
suckling, especially where the children are large and the mother 
delicate.. In the cases of a number of ladies of this city, this 
cause produced pain of chest, cough, sanguineous and purulent 
expectoration, night sweats; yet they were all cured by weaning, 
and the tonic treatment. 

Fluor albus, menorrhagia and hemorrhage of any sort, by the 
debility induced, predispose to phthisis. 

Mr. Hey, in his observations on surgery, remarks that he has 
seen a great number of cases of pulmonary consumption, the 
consequence of debility, induced by violent hemorrhages, and in 
persons who had no apprrent tendency to consumption, (p. 253.) 

Debility, from the want of accustomed stimuli, has the same 
effect. This is a pregnant source of consumption in the State 
Prison. Deprived of their accustomed indulgence in animal 
food and spirituous drinks, exercise in the open air, and especially 
deprived of their liberty, phthisis is not an unfrequent conse- 
quence. The same effect is produced by the depressing passion 
of grief; by excessive venery; by onanism; by the debility from 
the intemperate indulgence in spirituous liquors. 

5th. Pneumonia from cold is one of the most common sources 
of consumption, with or without predisposition; but more com- 
monly where such hereditary tendency exists. — Two young la- 
dies, my patients, who have a strong predisposition to this disease, 
are every autumn and winter thus affected; but by the active anti- 
phlogistic treatment in the first stage, and the tonic plan in the 
second, even when the purulent discharge, tinged with blood, and 



PHTHISIS PULMONALIS. 565 

the regularly flushed cheek and night sweats have taken place, 
have been regularly relieved. 

Measles, small-pox, syphilis — mercury, repelled eruptive dis- 
eases also predispose to pulmonary consumption. In like man- 
ner, the suppression of accustomed evacuations, as suppression of 
the menses, and the natural cessation of the catamenia frequently 
lay the foundation of pulmonary consumption. 

6th. In young women the suppression of the menses is the 
consequence as well as the cause of phthisis. It is too justly a 
source of great alarm. The usual remedies, too, prescribed; viz* 
stimulants to restore them, are improper, and oftentimes highly 
injurious, the prescriber not regarding the real cause of the 
disease. 

It is important here to distinguish between suppression, accom- 
panied with irritation of the chest, and general febrile symptoms, 
and that form of suppression which is connected with dyspepsia 
and consequent pulmonary irritation; for in the one case, the 
antiphlogistic treatment is called for: whereas, in the other, iron 
and other tonics are indicated. 

7th. A variable climate predisposes to phthisis. The eastern 
coast of this country, exposed to north-east winds, and great vi- 
cissitudes, and Great Britain, owing to its insular situation, and the 
moisture in which it is continually involved, are in a peculiar man- 
ner liable to pulmonary diseases. Holland, though a moist coun- 
try, is, from its mild temperature, an exception. Dr. Cogan, who 
practised in Holland, states that colds and coughs are compara- 
tively much less frequent in that country than in England. In 
like manner, phthisis is less prevalent in the fenny parts of Lin- 
colnshire than in the highlands of the same county. Where 
agues prevail, there are few consumptions. In the interior of 
the United States, and on the continent of Europe, phthisis is 
less prevalent; and in warm climates, it is comparatively a dis- 
ease of rare occurrence. Lithiasis, or calcareous deposits in the 
lungs, lay the foundation of this disease. A case is related by Clau- 
trey, in Sedillot's Journal, where a piece of bone was so lodged 
fourteen years; and another by Holman, where one was so fixed 
fifteen years, (Med. Trans.) where the system was nearly wasted 
by this cause ; but by the removal of those substances was 
restored. Bones, or a cent, sticking in the oesophagus, (see Good,) 
have, in like manner, produced a marasmus. 



S66 LECTURE XLVI. 

9th. Extraneous matters received into the lungs, are usually- 
enumerated among the predisposing causes of phthisis. Hence 
millers, bakers, stone-cutters, coal-heavers, laboratory-men, scythe- 
grinders, chimney-sweepers, are the subjects of pulmonary con- 
sumption. In a cavern at Walshut, on the Rhine, in which mill- 
stones are dug and worked, a fine dust is constantly floating, that 
even penetrates leathern bags, and discolours money contained in 
them. The w r orkmen become consumptive, insomuch that it is 
endemic. No one can remain twelve months there without the 
disease, and some are immediately affected; and that, too, not- 
withstanding the warm state of the air in that cavern, during 
winter as w T ell as summer. (Good, vol. ii. p. 747.) Dressers of 
flax and feathers — those engaged in the warehouses of leather- 
sellers, spinners in wool, are very subject to it — hence it is so 
frequent in Scotland. Two reasons are to be assigned for this 
fact; the fine particles of wool or cotton taken into the lungs, 
and the waste of saliva. Knitters in wool, from their sedentary 
habits, persons employed in pointing needles by dry-grinding 
them, are subject to this disease; and it is said, rarely attain to 
forty years of age. (Med. Memoirs of London.) 

The fumes of mercury, as you are will see stated by Ramaz- 
zini, and by Dr. Francis, in his Inaugural Dissertation, and we 
may add, the great heat to which the workmen are exposed on 
such occasions. The fine dust of coal, Fordyce supposed to be 
one cause of its great prevalence in London; but climate, proba- 
bly, has the greatest share; and we may add, the scanty and thin 
dresses of the fashionable females, and the heated and crowded 
rooms in which a change of temperature of perhaps 25° or 30° is 
experienced. We are sensible of the effect of these transitions 
upon our hands and fingers, how much greater must they be upon 
the exposed and tender surface of the lungs. The fumes of sul- 
phur irritating to the lungs, as in the manufactories of the sulphu- 
ric acid, injurious to vegetation, are very frequent causes of its 
production. 

10th. Trades and occupations — shoemakers, sitting and stoop- 
ing at their stalls; writing at a desk, for the same reason. Tay- 
lors too. The exertion of the lungs in blowing musical instru- 
ments; in the case of beginners especially. The application of 
great heat in segar smoking. Compression of the chest by dress. 






PHTHISIS PULMONALIS. 567 

The exertions of the lungs in public speaking. Cicero himself 
tells us in his book on orators, that he found it necessary to retire 
from the forum for two years, during which he travelled into 
Asia; and that he there recovered his health, and returned with 
renewed vigour to his profession. Moliere died of hemoptysis, 
immediately after performing, for the fourth time, his " Malade 
Imaginaire." (See Vanswieten's Aph. sec. 1201. p. 49.} 



568 



LECTURE XLVII. 



PHTHISIS PULMONALIS. 



The exciting or occasional causes of phthisis are numerous. A 
common catarrh, and especially if that is frequently repeated, 
ought in my opinion to stand at the head of the list of the exci- 
ting causes of pulmonary consumption; it is one of those causes, 
too, that attract the least attention, while it does the greatest 
mischief; for being seated in the mucous membrane of the bron- 
chise and the cellular substance of the lungs, which are compara- 
tively insensible, the evil becomes considerable before it calls 
either the attention of the patient, the parents or friends, or even 
the physician who has not been familiarly conversant with the 
fatal consequences of this disease. A catarrh neglected, either in 
its inflammatory or its chronic state, when there is the least pre- 
disposition to pulmonary complaints, frequently terminates in 
phthisis. Dr. Duncan, in his ]ate treatise on consumption, accord- 
ingly has denominated one of his species of consumption, catarrhal 
consumption ; his second, apostematous consumption ; third, tu- 
berculer. This is a bad distinction — they run together at the 
bed-side, and are not to be distinguished. 2. For the same reason 
that a catarrh will create a determination to the chest, and con- 
gestion and inflammation in the lungs, constituting phthisis, so 
also will the various forms of pneumonia produce similar con- 
sequences, especially if not actively treated, and as a peculiar 
predisposition to phthisis exists, either from make of chest, an 
hereditary scrofulous habit, or any other of the predisposing 
causes which have been noticed. A pleurisy or peripneumony 
ending in empyema or vomica, not unfrequently thus terminates 
in phthisis; constituting the apostema of Dr. Duncan. Yet it is 



PHTHISIS PULMONALIS. 569 

to be remembered that suppuration in the lungs does not inva- 
riably or necessarily induce consumption, as some suppose. 
The opinion of many that the agitation of the lungs in respi- 
ration, and the constant exposure of the ulcerated lungs to the 
air, prevent those ulcers from healing, is certainly not correct ; 
on the contrary, where the patient has no peculiar predispo- 
sition to this disease, nor a great previous debility of consti- 
tution, ulcers in the lungs will frequently heal as readily as in 
other parts of the body. 3. Tubercles are usually enume- 
rated by writers among the exciting causes of phthisis ; in my 
opinion they are not the causes of phthisis, but are the conse- 
quences of the previous inflammation, and constitute therefore a 
part of the disease, instead of being exciting causes of the disease. 
What are tubercles? They are usually described as small circum- 
scribed tumors, formed in different parts of the lungs, and filled 
with purulent matter; as their name imports, they are small tumors 
(the diminutive of tuber. ) But of what do they consist, and how are 
they constituted ? In most instances they contain purulent matter, 
but in others none; exhibiting a mass of condensed cellular mat- 
ter in the state of scirrhus. Are these, as supposed by many, en- 
larged and ulcerated glands ? Do such glands exist in the lungs ? 
I believe not; nor is it necessary to have recourse to a glandular 
structure to explain these phenomena; for we see precisely simi- 
lar tubercles formed in the parenchyma of the brain, of the liver, 
and of the kidneys, when surcharged by inflammation and con- 
gestion, in which no small glands have yet been detected, in which 
as in the lungs there is nothing but cellular matter and vessels. It 
is, in my opinion, an union of a number of these cells in a state of 
congestion, that constitutes these tubercles or vomicae. If we advert 
to the fulness and swelling of the hands, which frequently takes 
place after exposure to the cold and the return to a heated atmos- 
phere, we can easily imagine the turgid and distended condition 
of the distensive cellular substance of the lungs, and that during 
such fulness and inflammation, that they should occasionally ad- 
here, constituting this inflamed mass, denominated tubercles, in 
which matter shall be effused. In some instances these tubercles 
or vomicae heal, the matter is absorbed, and they remain in a scir- 
rhus state, and the patient is perfectly restored. And even wher 
matter is formed, phthisis does not necessarily follow, any more 
than after a large vomica; hence the remark of Dr. Simmons, that 
49 



570 LECTURE XLVII. 

tubercles may exist without phthisis ; but whether tubercles be 
enlarged glands, or a congeries of the cells of the lungs, they ne- 
cessarily imply a preceding inflammation. Hence it is that writers 
agree in enumerating tubercles among the most usual exciting 
causes of pulmonary consumption, while they do not advert to 
the inflammation itself that precedes and begets the tubercles. 
" Tubercles/' says Dr. Baillie, " consist of rounded, firm, white 
bodies, interspersed through the substance of the lungs. They 
are, I believe, formed in the cellular structure which connects the 
air cells of the lungs together, and are not a morbid affection of 
glands as has frequently been imagined. There is no glandular 
structure in the cellular connecting membrane of the lungs; and," 
he adds, " on the inside of the bronchia? and trachea where there 
are follicles, tubercles have never been seen. 7 ' Another exciting 
cause of phthisis, and which, by Dr. Cullen and others, is con- 
sidered as the most usual source of the disease, is hemoptysis. 
Such indeed is Dr. Cullen's belief on this subject, that he places 
phthisis under that head in his nosology — considering the two dis- 
eases as inseparable. But how stands the fact ? That such rupture 
of a vessel in the lungs, is in some cases the immediate cause of 
inflammation and ulcer, terminating in a fatal consumption, is not 
to be questioned; but yet that it is so frequently followed by it, as 
some writers have represented it to be, is not true. Cases of 
hemoptysis in which recovery succeeded, are numerous. The 
late king of Prussia, according to Dr. Zimmerman, was fre- 
quently attacked with it during his seven years war; yet he lived 
upwards of twenty years afterwards without pulmonary consump- 
tion. Dr. Rush, of Philadelphia, frequently bled at his lungs in 
early life, yet lived to an advanced age, in the constant exercise of 
his lungs, as a public teacher of medicine in the University of Penn- 
sylvania. His pupil, Dr. Edwards, was prescribed for by him in 
1769; yet he lived till 1802 — he seldom passed a year without 
spitting blood— yet its consequences were prevented by venesec- 
tion, and the occupations of a country life. 

Bleeding from the lungs indeed may be said, in some in- 
stances, I believe, to have actually prevented consumption by 
doing what the physician ought to have done, that is, by unload- 
ing the inflamed vessels; and indeed it may be remarked that a 
rupture of a vessel of the lungs is not a frequent occurrence, ex- 
cept where previous congestion has taken place, the effect of cold 



PHTHISIS PULMONALIS. 571 

or some other cause inducing inflammation, and has been ne- 
glected. Dr. Rush relates two cases of such recoveries, wherein 
the patients lost a quantity of blood from the lungs, and the Doc- 
tor very properly, I believe, ascribes their recovery to these 
spontaneous bleedings. I find, too, that Dr. Young remarks, in 
his valuable Essay on this subject, that hemoptysis in a healthy 
constitution is not materially formidable, and that when it appears 
to produce consumption, it has itself been occasioned by an inci- 
pient obstruction of a different kind. (See Good, vol. 2. p. 743; 
Young, p. 45.) Desault, too, says it is hemoptysis from con- 
sumption, not consumption from hemoptysis. (Ibid.) In some 
instances phthisis has been occasioned by other diseases as the ex- 
citing cause — as dyspepsia. Dr. Wilson Philip makes a species 
which he calls dyspeptic phthisis. If the irritation of the stomach 
will excite the lungs to coughing, it is capable of producing all 
the consequences of irritation. Asthma is accordingly so con- 
sidered; but this operates most usually as a predisposing, instead 
of an exciting cause. It may, however, in some cases excite the 
disease by its long continuance, and the congestion of the lungs 
attendant upon it. A lady of this city, and another of Phila- 
delphia, will probably both fall victims to consumption; 
they now suffer violent attacks of asthma, the paroxysms of 
which are frequently produced by change of weather, or by other 
causes, as violent impressions made upon the nervous system, 
either by mental or bodily agitation. 

Scrofula is also said to be a frequent exciting, as well as predis- 
posing cause of phthisis. Some suppose scrofula to be a disease 
exclusively the effect of debility, because it is attended with a 
debilitated state of body; while others consider it as the effect of 
a peculiar virus in the system. A fact which, in the opinion of 
some, decides this question, is that they see scrofula communi- 
cated to children by suckling, while we see nurses labouring un- 
der infinitely greater debility from other causes, giving suck and 
yet communicating no strumous affection to the child. 

I have seen them in this way labouring under scrofula, go from 
child to child, and communicate the disease. In other instances 
the child inherits the glandular affections of scrofula from the 
mother thus tainted, while in other respects the mother enjoyed 
good health, and even vigour of constitution.. The poison of 
syphilis also produces phthisis where there is the least predispo- 



572 LECTURE XLVII. 

sition to pulmonary complaints. Morton states a case illustrative 
of this fact. 

Contagion is supposed by some physicians to be the medium 
of communicating phthisis. Such is the belief on this sub- 
ject among the physicians of the south of Europe, that phthisis is 
there communicated from person to person, that a law exists in 
some of the Venitian states, making it obligatory to burn the 
clothes and furniture of those who die of pulmonary consumption. 
(See Smith's Tour on the Continent of Europe.) A similar 
opinion was entertained of the contagious nature of consumption, 
by Aristotle, Galen, Morgagni, Van Swieten, and Morton, (See 
his Physical Library, Cap. 1.) Hoffman, Vogel, Desault, Darwin, 
and most modern writers. Dr. Heberden states that he has seen 
many persons die of this disease in whom contagion was the most 
probable cause of the disease, contracted from their constant com- 
panions or bed-fellows. Dr. Thomas states that two or three well 
marked cases of this nature have fallen under his observation. 
Dr. Rush relates the fact that this disease spread from the pro- 
prietors of an estate to the negroes, among whom it scarcely ever 
makes its appearance, and who were not related to the first victims, 
nor predisposed to phthisis. Dr. Rush related to me a case of a 
healthy, robust, black servant woman, in New Jersey, not in the 
least predisposed to the disease, who thus contracted it. It was 
her duty to wash the handkerchiefs of her mistress, who was ill 
and dying of that disease. She herself constantly receiving the 
warm effluvia loaded with purulent matter, in a short time be- 
came the subject of the same complaint and fell a victim to it. 
The matter may certainly be thus conveyed to the irritable sensitive 
surface of the lungs and cause the same inflammatory disease. It is 
also a common opinion that one person sleeping with another ill 
of phthisis thus contracts the same disease. It may certainly be 
thus communicated in the same manner as the matter of ophthal- 
mia brought in contact with the tender surface of the eye will ex- 
cite inflammation; so may it produce a similar effect upon the 
irritable surface of the lungs. Dr. Good remarks, (p. 165, 
vol. 2.) that it is not often that phthisis commences with in- 
flammatory action ! ! If he had said that it is not often that it 
does not commence with inflammatory action, it would have been 
nearer the truth, and unless we say that it invariably commences 
in this manner, we do not tell the whole truth. 



PHTHISIS PULMONALIS. 573 

The proximate cause of this disease I consider to be an inflam- 
mation of the lungs, but not debility which makes the proximate 
cause of Dr. Rush, ending in either purulent excretion or an ulcera- 
tion in the substance of the lungs. Let me also add that the matter 
contained in such ulcer or ulcers, tubercles, or vomicae, by whichso- 
ever name you may please to denominate them, may be either dis- 
charged by expectoration, or may be inclosed without such dis- 
charge. Another remark is, that in case of expectoration, it may 
either be attended with hectic fever, or the patient may be wasted 
without such fever, as in the cases referred to by Fothergill and 
DeHaen. But in all cases, inflammation followed by a purulent 
secretion is essential to constitute the proximate cause of 
phthisis. But the pus so secreted when absorbed in considerable 
quantity from the lungs, as from abscesses in other parts of the 
body, produces the regularly formed hectic; yet it may not be 
absorbed, and the patient still expectorate largely; in which case 
the patient wastes without hectic fever. But how do we know 
whether the matter discharged be pus or the natural mucus of 
the lungs ? This leads me to make a remark or two upon the 
distinctions which have been proposed upon this subject. In the 
first place, pus is opaque; mucus is comparatively transparent; 
pus is more friable, easily broken up by agitation with water; 
mucus is more viscid and tenacious, and is not easily diffused in 
water. Pus, that is, when warm, emits for the most part, an 
offensive smell — mucous has no smell. Pus has a greater specific 
gravity than mucus; accordingly pus sinks in water, while mu- 
cus floats. Let me, however, observe that pus, when mixed 
with a considerable quantity of mucus, will be suspended by the 
air which is usually involved in the mucus. Dr. Charles Dar- 
win has furnished some additional chemical tests by which these 
two substances may be distinguished. 1st. Dissolve pus in sul- 
phuric acid; if you add water to the solution, a precipitate is pro- 
duced; but from mucus treated in the same manner, there is no 
precipitate. 2d. Dissolve pus and mucus in caustic alkali, and 
add water to the two solutions — the solution of the pus throws 
down a precipitate — the mucus none. Another test is, that muri- 
ated quicksilver will coagulate mucus, but will not coagulate pus. 

Dr. Young, or rather Home,* has lately discovered another 

* Dr. Everard Home distinguishes pus from mucus, 1. By its consistence, 
which he observes, is of the consistence of cream. 2. Its whitish colour. 3. Its 
4.9* 



574 LECTURE XLVII. 

test by which pus is to be distinguished from mucus: that pus, 
like the blood, contains regular globules which are distinctly to 
be seen by means of a glass; but the mucus looked at in the same 
manner, possesses no such globules. The following is Dr. 
Young's own language on this subject : 

" Where the greater number of the pustules are nearly equal 
in dimensions, a luminous object viewed through them, is sur- 
rounded by rings of colours, somewhat resembling those of the 
rainbow, but differently arranged, and often beautifully brilliant. 
The blood, a little diluted, always exhibits them in great perfec- 
tion, and they afford a very accurate criterion for the distinction 
between pus and mucus. Mucus, containing no globules, affords 
no colours, while those which are exhibited by pus exactly re- 
semble the appearance produced by the blood, the rings being 
usually of the same dimensions. A minute quantity of the fluid, 
to be examined in this manner, may be put between two small 
pieces of plate glass, and if we hold the glass close to the eye, 
and look through it at a distant candle, with a dark object be- 
hind it, as a piece of green cloth, the appearance, if the globules 
are present, will be so conspicuous as to leave no doubt respect- 
ing their existence." (See Young's Introduction to Med. Lit. 
p. 547, or Quart. Rev. for March 1813, No. 17, p. 124.) Obser- 
vations on the coagulation of the blood, and on the globules of 
pus, compared with those of the blood. (See Royal Society's 
Trans. 1818, Part 1.) 

DIAGNOSIS. 

But there are certain diseases which bear some resemblance to 
phthisis. What are they, and how are they to be known? 

1st. Tussis stomachica, a cough so denominated by Dr. Stoll 
of Vienna, because it proceeds from the irritations primarily seated 
in the digestive organs, and thence producing pain in the chest 
and cough sympathetically. This is to be known — 1st, by the 

mawkish taste. 4. Its want of smell when cold. 5. Its peculiar smell when 
warm. 6. Its semi-opaque globules and, transparent colourless fluid when looked 
at through the microscope, which fluid is coagulated by the muriate of ammonia. 
7. Its evaporating to dryness without coagulating. 8. Its specific gravity being 
greater than water. 9. Its not putrifying readily. 10. Its being not easily dif- 
fused in cold water. 11. Its being readily diffused in warm water, and then re- 
maining so after it cools. 



PHTHISIS PULMONALIS. 575 

blueish colour of the matter discharged in the morning, and in 
lumps. 2d. The cough is only, or chiefly, at that time trou- 
blesome. 3d. It is accompanied with the other evidences of a 
disordered stomach, foul teeth, and the tongue loaded with a 
yellowish sordes, with a disagreeable taste, and an offensive breath. 
4th. It is most troublesome, and the expectoration greatest after 
a hearty supper, which, remaining undigested, excites great irri- 
tation, and other signs of a disturbed state of the digestive pro- 
cess, that frequently bilious vomitings also attend this disturbance 
of the stomach. In like manner, head ache and vertigo are its 
occasional concomitants from the same cause. 5th. It is cured 
by emetics, cathartics, and tonics; and usually increased by the 
depleting means found most beneficial in phthisis. 

2d. Chronic catarrh and tussis senilis, are nearly allied to phthi- 
sis, and sometimes terminates, in actual pulmonary consumption; 
but, for the most part, chronic catarrh consists in an increased 
secretion of viscid mucus, and is frequently removed by tonics. 

3d. Asthma, especially humoral asthma, the nature of the dis- 
charge being, for the most part, mucous, and the disproportionate 
dyspnoea, and that returning in paroxysms, readily characterise it 
in most cases. But I attended a lady in this city, very subject to 
this disease, especially upon taking the slightest cold. In her 
case, every such attack of inflammation is so violent that it is 
followed, not by a mucous secretion, but a manifestly purulent ex- 
pectoration, as much so as any I ever witnessed in phthisis; still 
that lady has been regularly relieved by tonics and stimulating 
nourishment: I mean given in its second stage, not in the first: 
in the first, antiphlogistic means are employed. Although she 
discharges pus in abundance, there is here certainly no ulceration; 
but I am confident phthisis will be the termination of her life, 
for she has a strong predisposition to the complaint, not only as 
inherited from her family, but as it is manifest by her own make 
of chest and delicate habit of body. She is now ill — in the use 
of emetics in nauseating doses, Dover's powder; i. e. while febrile 
symptoms continue — in a few days I shall give her tonics. The 
matter expectorated is purulent, and in immense quantities. 

4th. Vomica. — The frequent chills, the preceding inflamma- 
tion, dyspnoea, and the sudden discharge of the matter so accu- 
mulated, will readily characterise vomica; but this same vomica, 
when discharged, may leave phthisis as a consequence, especially 



576 LECTURE XLVII. 

where predisposition exists to pulmonary disorders. In like 
manner, 

5th. Empyema may, under similar circumstances, destroy the 
patient by phthisis; but in its first stage, the local affection of the 
side, the tumour, the dyspnoea, the preceding pleuritic inflamma- 
tion, all clearly designate it. 

6th. Abscess of the liver — this disease is characterised by the 
pain in the right hypochondrium, and shooting to the shoulder. 
The preceding fever is without cough, in the commencement. 
The sallow complexion of the patient, for the most part, readily 
points out this disease. 

7th. Oesophagitis. — An inflammation and ulceration of the 
oesophagus and cardiac orifice of the stomach. Here matter is 
discharged by vomiting. Bayle notices the same form of phthisis 
in his enumeration: viz. his Melanosis. 



577 



LECTURE XLVIII 



PHTHISIS PULMONALIS. 



Treatment — quomodo curatur phthisis? nescio. From the 
view which has been taken of the symptoms constituting the ap- 
proach, as well as those marking the progress of phthisis, we are 
led to two indications in its treatment. 

1st. During the acute or inflammatory stage, as in pneumonic 
inflammation in general, to cut off the determination of the blood 
to the chest; this is to be accomplished by the usual means of de- 
pleting the system in other inflammatory diseases, and especially 
by early and repeated bloodletting; its repetition is not to be 
directed by the buffy coat which appears on the blood drawn, for 
as a late and able writer observes, " in phthisis, the buffy coat 
appears as long as the arteries have power to propel the blood." 
(See Rees. Art. Consumption. Dr. Bateman.) This fact has 
already been frequently noticed as occurring in other febrile dis- 
eases, as intermittents, typhus and yellow fever, in the advanced 
stage of which, the buffy coat appears, when it did not show itself 
in the first stage of those diseases ; and therefore the lancet is 
not indicated by such appearance of the blood. The evidences 
derived from the quality of the blood, have also been pointed out 
to you, as consisting in a viscidity and redundance of the crassa- 
mentum, the firmness with which it coagulates, and its dark 
colour. Your guide with regard to venesection, in the first stage 
of phthisis, must be the pain of the chest; while the cough conti- 
nues dry and painful, or the patient experiences soreness in cough, 
upon taking a full inspiration, the lancet must be repeated; even 
although purulent matter be discharged in great quantity; al- 
though the hectic fever be regularly formed by its absorption ; 



578 LECTURE XLVIII. 

although the patient be wasting by such fever and its attendant 
night sweats, bloodletting is to be repeated, for the removal of the 
inflammation which keeps up such soreness, and extends such 
ulceration, and continued, proportioning, however, the quantity 
to be drawn to the strength of the patient, and the habit of body? 
&c. ; but at the same time other means of diminishing external 
action, and of diverting the inflammation from the part affected, 
are to be had recourse to. Dr. Dover bled fifty times in succes- 
sion if not subdued. Miss , during the first winter of her 

attack, was attended by Dr. Post and myself. She was relieved 
by venesection and other means. Bloodletting was repeated 
five or six times. Another winter she was attacked in a similar 
manner; and another physician was called upon, who declined 
venesection; leaving her to a milk diet, the Lichen Islandicus, 
ptisanes and glysters. In a few weeks, the case terminated, as 
was to be expected, fatally. 

A second means of removing the inflammation constituting the 
first stage, is by purgative medicines, especially the saline and 
mercurial purges; these should be early prescribed in this disease. 

?d. Another means of counteracting the excitement in the 
chest is by the use of emetics, especially those calculated to dimi- 
nish febrile action, by their operation upon the excretions of the 
whole system ; such are the emetics of antimony, or of ipecacu- 
anha, or these combined ; which combination has already been 
recommended to you, as preferable to either, separately. Full 
vomiting, however, should not be directed until the lancet and 
other means of depletion have been previously employed; other- 
wise, in the congestion of the lungs constituting this stage of the 
disease, a vessel may be readily ruptured by the operation of an 
emetic, and thereby greatly aggravate the complaint, instead of 
affording relief. Dr. Reid, as you will find upon perusing his 
excellent work, places an almost exclusive reliance upon emetics 
in phthisis; not in my opinion sufficiently availing himself of the 
other means of depletion, in the commencement or first stage of 
the disease ; like those who rely exclusively upon calomel or an- 
timony, for the cure of croup; or the Italians relying upon anti- 
mony for the cure of pneumonia; or Senac upon warm water and 
antimony for the cure of dysentery; nor guarding against the 
debilitating effects of emetics in its advanced stage. Hence, this 
promiscuous prescription of them has, in many instances, done 



PHTHISIS PUXMONALIS. 579 

great injury. While properly employed, they are among the 
most beneficial means of removing general fever, and of translat- 
ing the disease from the chest by counteracting inflammation. 
As these febrifuge effects of vomiting are desired in this stage of 
phthisis, let me caution you against the vitriol emetics recom- 
mended by some writers — Maryatt's dry vomit, consisting of 
blue vitriol and tart. emet. aa. gr. iiss. — augments the violence and 
distress in this disease, as in laryngitis. The same has been also 
adopted by Dr. Simmons, (omitting the tartarised antimony, 
which is the best part of it in this stage of the disease.) Dr. S. 
prescribes from gr. v. to gr. xv. in a wine glass full of warm wa- 
ter, giving the patient a tumbler of the warm water before taking 
it and during its operation. Dr. Senter, of Rhode Island, as you 
will see in his paper in the Transactions of the College of Physi- 
cians of Philadelphia, prescribes, in this disease, the following 
combination of blue vitriol and ipecacuanha, viz: gr. vj. blue 
vitriol, gr. x. to gr. xv. of ipecacuanha. I had the pleasure of a 
personal acquaintance with that respectable and intelligent phy- 
sician; he accompanied me in my visits to the State Prison and 
New York Hospital, and, at his suggestion, I made trial of it in 
many cases of phthisis in the State Prison, and in some instances 
with manifestly good effects; but I did not then distinguish, as I 
now do, and wish you to do, the different stages of phthisis, or I 
should have confined myself to the nauseating and febrifuge eme- 
tics in the first stage, while I should prefer the vitriol emetics in 
the last, where it is frequently desirable to have the emetic 
effects alone, without the debilitating operation upon the whole 
system, analogous to their good effects in the second stage of per- 
tussis. 

A:. Epispastics furnish another important mean of translating 
the soreness or inflammation from the lungs. Under the head of 
epispastics are included blisters, setons, and issues. Dr. Lettsom 
and Dr. Simmons prefer setons to blisters, while Dr. Mudge ex- 
presses his preference for issues, ailed ging, that by issues he him- 
self was cured of this disease. If epispastics operate by the irri- 
tion they excite by the new inflammation they create in the part 
to which they are applied, blisters, which produce much greater 
irritation than either setons or issues, are certainly to be preferred. 
But in the last stage they are all injurious, by the debilitating 
discharge that attends them, and which only adds to the dis- 



580 LECTURE XLVIII. 

charges already expending the strength of the patient. In the 
typhus state, as Dr. Rush improperly calls it, the system is too 
weak to sustain the discharges of either of them. Let this class 
of remedies therefore be confined to the first stage of this disease, 
and used as early as possible; do not fear their application, how- 
ever you may hesitate upon other occasions to give pain; by these 
applications, in delicate habits, it is kindness to do it early in 
this disease. 

5th. Mercury, in small doses, so as to excite salivation, has 
been much employed in this disease; and where it has been 
attended with this effect upon the salivary glands, and has been 
given early in the disease, before the strength of the patient has 
been greatly reduced, it has certainly been administered with 
great success. Dr. Rush has recorded many instances in which 
it has effected cures of this disease. I have now two such cases 
on hand. In both, the disease exhibited many alarming symp- 
toms of confirmed phthisis, yet both were instantly relieved 
when the mouth became affected. The cough, anhelation, and 
other pulmonary symptoms immediately disappeared. But mer- 
cury, like venesection, emetics, or other useful medicines, has 
been very much abused by being given in the last as well as 
the first stage, when it is very difficult to affect the saliva- 
ry glands. To secure its effects on the mouth, it should be 
given in union with small quantities of opium. Mercurial 
ointment may also be employed as a dressing of your blister, 
instead of common cerate; and it may be used in the form of 
ointment applied upon the extremities; otherwise it proves cathar- 
tic and debilitating, without the salutary effect which it produces 
when it excites an inflammation of the salivary glands. Unless 
this effect be produced it only serves to hasten the patient to the 
grave. Dr. Cullen remarks of this medicine, that it is manifestly 
hurtful in consumption of the lungs. When it fails to excite the 
salivary glands, it renews and aggravates the inflammation in the 
lungs, and increases the purulent effusion, analogous to its effects 
in aggravating other inflammatory diseases, where it fails to affect 
the mouth. 

6th. In the first stage of phthisis, antimonial medicines, or 
ipecacuanha, administered in small nauseating doses, are also use- 
ful, by their effects upon the skin, and the secretions in general. 
They should, however, be confined to the first stage; i. e. while 



PHTHISIS PULMONALIS. 581 

soreness, stricture, and other symptoms of local inflammation 
remain; or they may be renewed by a fresh cold and fresh inflam- 
mation, in the second stage. The antimonial wine and lauda- 
num, or the antimonial solution, the mucilage of gum arabic and 
antimony or laudanum ; and a small quantity of paregoric elixir, 
where the cough is troublesome; or the liquorice mixture, 3ij-; 
antimony, 5j.; paregoric, 3iij.; water, svj.; may be advantage- 
ously prescribed — or Dover's powder. With the same view to 
promote the secretion by the skin, and to relax the surface of the 
lungs, the warm bath has been recommended; and the steam of 
warm water, to be received into the lungs by means of Mudge's 
inhaler. They doubtless are beneficial auxiliaries. 

7th. Diuretics are also depended upon by many practitioners, 
for their effects in diverting the inflammatory action from the 
chest by creating a new irritation in the system, and thereby a 
diversion of the fluids. (See Med. Obs. and Enq. vol. vi. p. 208.) 
Dr. Dixon, with this view, prescribes the nitrate of potash, and 
bestows upon it an high eulogium, pronouncing it equally valu- 
able in this disease with bark in an intermittent It may doubt- 
less prove a valuable medicine in the first stage of phthisis, espe- 
cially when produced by or accompanied with hemoptysis — in 
this case it will probably be most useful. Ten or fifteen grains of 
this medicine, with as much powder of gum arabic, or in an almond 
emulsion, may be given three or four times a day; but it must 
be cautiously persisted in, or it will greatly impair the tone of 
the digestive organs. Another medicine, to which great value 
has been attached, in the treatment of pulmonary consumption, 
is digitalis, or the purple fox-glove. This medicine operates as 
a diuretic, and by diminishing the arterial circulation, at the same 
time that it manifests a powerfully deleterious or sedative opera- 
tion upon the brain and nervous system. Some suppose it to 
produce a peculiarly stimulant operation upon the absorbent sys- 
tem, and that by promoting absorption it enables the ulcers in 
phthisis to heal. If digtialis be at all serviceable in this disease, 
it can only be so in the first stage, and then by its sedative and 
diuretic operation, and thereby diminishing the general morbid 
excitement of the system. It operates then by lessening the 
increased action of the heart and arteries, and consequently 
diminishes the flow of blood to the lungs; and not as supposed 
by any specific operation upon the absorbents, for it is contrary 
50 



582 LECTURE XLVIII. 

to all reasoning, indeed it is madness to suppose that a medicine 
which it is said so powerfully to diminish the action of the heart 
and arteries, should at the same time increase the action of the 
absorbents. And it is a fact, I believe very universally admitted, 
(see Edin. Pract. of Physic,) Dr. McGinnis's statement to the 
contrary notwithstanding, that in those cases in which it does not 
sensibly reduce the action of the sanguiferous system, it is attended 
with no advantage; on the contrary, that by its deleterious effect 
on the system it does infinite mischief. 

This medicine therefore, if at all beneficial in phthisis, should 
only be administered in the first stage of the disease, while both 
the general and local inflammatory symptoms continue, and be- 
fore the strength of the patient has been much impaired. Certain 
it is, says Dr. Thomas, in his 4th edition, that its success is pro- 
portioned to its early exhibition. But in the second stage of the 
disease, I know nothing which hurries the patient more rapidly 
to the grave, than the deleterious and debilitating effects of this 
poison. I have frequently prescribed it and seen it prescribed; 
and in many cases, contrary to my wishes, it has been given in 
the advanced stage of phthisis — invariably with fatal effects. 
Digitalis, as its name imports, is a finger-shaped flower; it is 
a finger which points to the grave, especially when thus indis- 
criminately exhibited. In the first stage it may be salutary as an 
auxiliary to the other means which have been directed, but then 
it is not to be trusted without them. Indeed, one writer, Dr. 
McLean, (see Thomas,) observes, {i that this is all he apprehends 
that it will be found capable of performing;" and adds, that 
"those who expect wonders from it, or that it will in general cure 
consumption, will be disappointed." Dr. Rush, after his long 
experience of it, observes, I am sorry to acknowledge that in 
many cases in which I have prescribed, it has done no good, and 
in some it has done harm. Dr. Duncan, senior, in his late work 
on phthisis, also expresses his disappointment in the effects of 
this medicine, and that, too, after long and extensive experience 
of its effects. (Read also Bedingfield, articles consumption, p. 101, 
2, 3, and Hemoptysis, p. 108.) Dr. Parr, too, very positively as- 
serts that it is more injurious than beneficial. (Diet. vol. 2. p. 
401.) But if you choose, give your patient the chance of being 
cured or destroyed by it. There are two modes of administering 
this medicine, in tincture and in decoction or infusion. The 



M 



PHTHISIS PULMONALIS. 583 

formulae of these you will find in all the books, in Thomas, the 
Dispensatory, &c. f&. gi. of the dried leaves, to sviij. of proof spirit; 
or which Dr. McLean prefers, ?iv. of the fresh leaves, to §v. of 
the rect. sp. of wine — M. Digest seven days, then strain. Begin 
with from x. to xv. gtt. three times a day, increasing two drops 
every second day. Dr. Fowler, of Stafford, uses it in decoction 
and infusion. For the decoction, he boils gij. of the fresh leaves 
in a pint until he can strain from it gvijss. and adds the tinct. 
cardamom, gss. M.: giving gss. twice, thrice or four times a day. 
The infusion, gi. of the dried leaves, sviij. boiling water — M.; 
strained. Give gss. to gvi. at a dose. We may say nearly the 
same thing of the prussic acid that we do of digitalis, that its 
debilitating and deleterious operation on the brain more than 
counterbalances any good that has been derived from its operation 
in retarding the circulation. 

The diet of the patient in the first stage of phthisis, as in the 
more violent forms of pneumonic inflammation, should be strictly 
antiphlogistic — animal food and stimulating drinks of every de- 
scription, should be totally proscribed. Snake-root, horehound, 
boneset, because they have been found useful in the second stage, 
have been by some directed in the first; nothing can be more 
improper, for if they possess active properties, this is not the occa- 
sion that calls for them. Let your patient be confined to vegetable 
nourishments, to milk, to fruits. Hoffman states that he has known 
a case of confirmed phthisis cured by confining the patient to fresh 
fruits, particularly strawberries in their season, and soft mucilagi- 
nous diluents, viz: barley, sago, flaxseed, bran tea, lichen islandi- 
cus. This last article as far as it contains the virtues of a bitter 
and tonic, which it does to a certain degree, is preferable in the 
second stage of this disease. Regnault directs it as a specific in 
this disease, and to be taken in every stage of it. Milk, if it be 
found to agree with the patient, may also be made use of; but 
with some persons it is much more difficult of digestion than even 
solid animal food. In that case, too, it will add to the excitement 
of the system, and should be prohibited; but otherwise, it is cer- 
tainly a very proper article of diet, especially when diluted. 
Asses and woman's milk are in many parts of the world preferred 
to cow's milk. It is much thinner, and the coagulation from it 
less in quantity, and less firm than that of cow's milk or goat's 
milk. In a delicate stomach, therefore, they may be preferable; 



584 LECTURE XLVIII. 

but usually diluted cow's milk, especially if conjoined with lime- 
water, in case of acidity, agrees well with most persons. Vinegar 
or the acetous acid has been recommended. Yet some ascribe the 
disease to this as the cause. It may be of dyspeptic phthisis. A 
case is told by Desault, in which it was thus produced in less than 
a month. Galen recommends it as the cure of phthisis. Dr. Gre- 
gory, too, relates the case of a patient who recovered by taking 
three dozen lemons daily ! The Moorish physicians also use vine- 
gar, gvii. diluted and sweetened, every twenty- four hours; its 
effects are to check night sweats, and to produce costiveness. 



REGIMEN. 

Attend particularly to the state of the air in which your patient 
may be situated. Remember a warm, temperate climate, is most 
favourable in pulmonary complaints. On this account, if practi- 
cable, send your patient to a warm climate without delay, espe- 
cially in the autumn, for the transition of the winter season 
always adds to the disease. If such change of climate be not 
practicable, your next best resource is to confine your patient to 
a warm room, observing to keep it at a proper temperature, say 
from 60 to 65°. The dress should consist of flannel or cotton 
shirts, worn next the skin, with sleeves; worsted drawers, socks, 
or stockings. And these should be frequently changed, at least 
twice a week. 

When the second stage of this disease has arrived, attended 
with a copious expectoration, and all soreness and pain have been 
removed from the lungs, our second indication is to diminish the 
discharge of pus, by giving tone to the vessels of the chest, and 
of the system in general, and by diverting the determination 
which takes place to the lungs, and which still continues, to other 
parts of the body, and thereby to diminish the expectoration. If, 
however, as is sometimes the case, the purulent expectoration is 
accompanied with the symptoms denoting active inflammation, 
especially pain upon taking a full respiration, or if pain be severe 
upon coughing, remember the antiphlogistic treatment is still to 
be persisted in, viz: venesection, blisters, and antimonial diapho- 
retics, with dilution, as in the first stage. But when all soreness 
is removed, as in chronic catarrh, or abscesses after pneumonia, 



— 



PHTHISIS PULMONALIS. 585 

our object is to change the current from the chest and to close the 
relaxed or diseased vessels; and that too, whether the discharges 
be from the surface of the lungs, or from a broken texture of the 
cellular portion of the lungs themselves: in either case a cure has, 
in many instances, been effected by active treatment. 

When we see the disease of the chest diverted by pregnancy, 
as is oftentimes the case, and when we see it cured by mania, in 
other words by a new determination to the brain, as stated by Dr. 
Cullen; I say, when such new determination to the uterus, and 
to the brain, or to other parts of the body, relieves the chest la- 
bouring under phthisis, let us, as far as possible, imitate these 
changes by art. Upon this principle, apply stimulating plasters to 
the surface of the body, as the emp. calid.; or apply blisters, con- 
fining them however, to their stimulant effects, and not suffering 
the patient to be debilitated by excessive discharges. Antimonial 
ointment produces good effects in this case. Another means of 
preserving the determination to the skin, is by flannel, worn next 
the surface, and especially by a warm climate; and in correspond- 
ence with this principle, it is universally remarked, that patients, 
affected with pulmonary complaints, are relieved by the perspira- 
ble state of the surface, and the copious secretions generally, 
which take place during the summer season. It is also remarked, 
by practical observers, that tubercles are both induced and in- 
creased in the winter season, but that they are retarded and fre- 
quently removed by the warmth of summer. (See Thomas, p. 
424.) Hence then it is desirable to keep the patient constantly 
in this temperature, either by going to a warm climate, or imita- 
ting it by creating a similar temperature in the apartments of the 
sick. Accordingly it has become sanctioned by the experience 
of every physician, that the removal of patients from northern 
climates to the island of Madeira, Italy, Spain, the south of 
France, the southern states of our own country, or to Bermuda, 
is attended with the most beneficial effects, provided the strength 
of the system be not already too much exhausted ; but it is a very 
just observation of Dr. Fothergill, speaking of the delay of pa- 
tients in changing their climate, that "it seems to be the fate of 
consumptive patients to do that last which they ought to have 
done first." (Med. Obs. and Enq. vol. 5. p. 369.) The island of 
Madeira is generally preferred to most places, as the resort of the 
consumptive, and very properly so, for the thermometer in win- 
50* 



5S6 LECTURE XLVIII. 

ter is never below 58° to 65° — nor rises in summer beyond 70° to 
75°. Dr. Adams, who lias written in praise of Madeira, observes 
that its climate is so uniformly mild, that it may be considered as 
a specific in that disease* The valley of Funchal, in particular, 
is so situated and defended by hills, excepting on the south, that 
it affords to the invalid complete protection against the winds to 
which, in the islands, in warm latitudes, he is otherwise exposed. 
It is no objection to Madeira as a place of resort for the consump- 
tive, that persons are occasionally exposed to that disease in that 
island ; for the stranger from a colder latitude will still profit by 
the change of temperature. But this is not all the advantage to 
be obtained ; otherwise a warm atmosphere artificially produced 
at home, would be equally beneficial ; but the patient has the ad- 
vantage of a voyage at the same time, and the benefits of daily 
exercise in the warm but open air, after his arrival. But when 
this change is impracticable, as frequently is the case, our next 
best resource is to regulate the temperature of the patients cham- 
ber, and, as far as possible, to create a West India or tropical cli- 
mate at home, as recommended by Dr. Buxton, in his book on 
temperature. 

He advises a degree of heat from 65° to 6S° to be preserved in 
the chamber of the sick, and to be regulated by the thermometer. 
For this purpose the heat should be supplied by the German and 
Russian porcelain stove instead of that of iron. Dr. Buxton 
considers the iron stove as good as any other. Not so — the 
smell is unpleasant; the heat, too, is less regular and uniform — 
iron being suddenly heated and suddenly cooled, exposes the 
patient to those changes of temperature that ought carefully to be 
avoided in the sick room. This practice of making a warm cli- 
mate he alleges, has been adopted with great success in various 
parts of Great Britain. It will also add very much to the com- 
fort and cheerfulness of the patient, and to the purity of the 
air, to supply the chamber with a number of living plants. In 
this situation the patient can enjoy every benefit, save that of ex- 
ercise, that can be obtained abroad. The next best substitute 
for the exercise of riding or sailing, is that of swinging, riding 
upon the chamber horse, or the exercise of battledoor or bil- 
liards. Swinging was introduced by Carmichael Smyth, who 
thought it equal to a sea voyage. Dr. Currie remarked to me, 
at Liverpool, at the Infirmary, where it had been faithfully 



PHTHISIS PULMONALIS. 587 

tried — that it had been of very little use — that he had never 
known a single instance in which it had effected a cure. I 
have also tried it in many cases in the State Prison, but without 
any perceptible benefit, and also in private practice. It has no 
advantage over the chamber-horse, rubbing furniture, or billiards. 
This is the most agreeable of all exercises; at the same time very 
amusing, and calculated to expand the chest. Some physicians, 
for this last purpose, recommend the dumb-bell — but there is 
objection to too much exertion of the lungs. The exercises 
of the gymnasium are also favourable to the expansion of the 
chest, and to impart vigour to the limbs, and thereby to diffuse 
an active circulation through the system, and to counteract any 
partial plethora of the chest — hence the use in the education of 
youth of these exercises. But in this stage of the disease the 
uniform exercise attendant upon a sea voyage is oftentimes more 
beneficial than all other remedies besides. As soon as the more 
violent inflammatory symptoms of the first stage have been sub- 
dued, this remedy should be recommended. How does it ope- 
rate in producing these salutary effects? 

In the first place, the patient breathes a milder and more equal 
and uniform temperature of atmosphere. Even in winter, the 
ice of the rigging, with which a ship leaves our port, all disap- 
pears as soon as she is off the coast. 

2d. It probably operates by its effects upon the skin, promot- 
ing perspiration, which is always more abundant at sea than on 
land. It may also, too, in part, prove beneficial by the nausea and 
vomiting, which usually are produced by a first voyage, and 
which sensibly lessen the frequency of the circulation, and re- 
move fever. Emetics act upon the same principle. Sailing on 
the Tiber was a common prescription among the Roman phy- 
sicians. To these I believe the salutary effects of sailing and a 
sea voyage, are to be ascribed, and not as Dr. Thomas supposes, 
to the smell of tar, or as some others believe, to the greater pu- 
rity of the air at sea than on land. This is very questionable. 
Next to the beneficial effects of a sea voyage, is a journey on 
land, to a warmer atmosphere; and to such parts of the country 
as are more retired from the sea-shore; for on the coast in par- 
ticular, the patient is exposed to vicissitudes that are not experi- 
enced either at sea or in the interior of the country. Many 
persons in this city, afflicted with weak lungs, have profited, and 



588 LECTURE XLVIII. 

indeed have preserved their lives, by their annual journeys to the 
south, and passing their winters in South Carolina, Georgia, or 
Florida. Dr. Simmons, Rush, &c. all concur in this advice to the 
consumptive, both with the view to change of temperature, and 
to the beneficial effects of exercise. But exercise alone has been 
recommended from the days of Sydenham, in this disease. By 
him, riding on horseback was considered as no less beneficial in 
consumption of the lungs, than bark in an intermittent. But this 
doctrine is to be received with some limitation. It is not to be 
used in the first stage. In the second it has been employed often- 
times with the best effects. Stoll disagrees with Sydenham. A 
man in a consumption, if he mounts a horse, may ride to the 
banks of the Styx as certainly as if he were in a pleurisy. 
Stoerck brought on hemophysis and consumption by it. Dr. 
Hunt, a trustee of this college, was relieved of approaching 
phthisis, the effect of catarrh, and his life prolonged many years, 
by a long journey to the southern and western states. 

When is it to be used? — Not in the morning, as Dickson recom- 
mends — unless in the morning he considers it hurtful! Certainly 
it is a great abuse of this exercise, when the lungs are sore. At 
the same time that exercise and exposure to the air may be proper; 
i. e. all active inflammation having subsided, it will also be proper, 
during the intermission of fever, and especially in the early part 
of the day, to prescribe some mild tonic, especially some of the 
bitters that have been recommended in the passive stage of catarrh. 
With this view, an infusion of columbo root, gentian, chamomile, 
horehound, the lichen islandicus, or even the alcornoque may be 
administered, and will be well calculated to close the relaxed ves- 
sels, to give tone to the whole system, and thereby to afford the 
patient the best chance of healing the ulcerations that may exist 
in the lungs. 

Upon the same principle a great variety of stimulants and 
tonics have been directed, or rather we may say, that where such 
excitants have proved beneficial, it is in this stage of the disease 
that they have been found useful; and I may add, you will find 
them frequently recommended without the least attention being 
paid to the stage of the disease in which they ought or ought not 
to be directed. With this view various balsams have been re- 
commended by Morton; in like manner myrrh, and gum ammo- 
niac, made into a lac, and given in substance, have been pre- 



&± 



PHTHISIS PULMONALIS. 589 

scribed by Simmons, without distinguishing the stage in which 
they are to be administered, or in which they are to be avoided. 
He advises from gr. x. to gr. xxx. of myrrh to be made into 
bolus with honey, and given twice or three times a day. Another 
formula I have seen in use is the following : Ji. Gum ammoniac, 
gum assafcetida aa. 3ij., gum myrrh, gum camphor aa. 3j., balsam 
Peru 3j. M., syrup q. s. divided in pills lxxxiv. two to be taken 
every two hours. In like manner the fumes of different resins 
have been used ; and recently, Dr. Creighton has called the at- 
tention of practitioners to the steam or fumes of boiling tar, re- 
viving the attention that was once given to the same remedy in 
another form, that of tar water, so zealously recommended by 
the late Bishop Berkely, of Cloyne; but like every other stimu- 
lant of this nature, it can only be useful in the passive stage of 
phthisis, when all inflammatory action has subsided. In the Me- 
dical Commentaries you will also find a paper recommending 
aether inhaled by the lungs as a specific; this too has disappointed 
all who have reposed confidence in it. The bark by some has 
been highly extolled: in cases where the disease has been induced 
by debility, the effect of long suckling, fluor albus, dyspepsia, or 
menorrhagia, it has doubtless proved useful. Cases are accordingly 
related by Dr. Fothergill, in which it has thus proved a cure of 
the disease by arresting those excessive evacuations. You will 
find other testimony of its efficacy under similar circumstances 
in the first volume of the Medical Commentaries, by Chapman. 
Elixir of vitriol has been found of benefit in similar cases, and is 
oftentimes prescribed to restrain excessive sweating. The muriatic 
acid is also frequently recommended in France. But while sore- 
ness of the chest continues, both the bark and the mineral acids 
should be totally prohibited. In some cases the Virginia snake- 
root, and the seneka snake-root especially, taken cold, have been 
found useful as tonics and stimulant expectorants. Dr. Percival 
also attaches virtue to the sulphate of zinc as a tonic in phthisis. 
As an emetic in this stage of the disease, I yesterday observed 

that I have directed it with signal benefit in the case of J. E J s 

daughter, who was cured in the advanced stage of consumption, 
to the surprise of all her friends. Anodynes are also very much 
resorted to in phthisis, but for the most part very improperly, 
for they smother the fire that is consuming the patient within ; 
they debilitate the stomach, destroy the appetite, and relax the 



590 LECTURE XLVIII. 

whole system. There are, however, two cases in which they 
are useful in this disease: to arrest severe coughing when dispro- 
portioned to the other condition of the system, and all inflamma- 
tory action has been counteracted, and in diarrhoea. In that 
case the chalk mixture will be good; say, chalk 3ij. ; aq. 
menth. gij.; aq. font, giv.; laudanum 3ij., or paregoric, gss. M. 
a tablespoonful occasionally. But the usual prescription of opiates 
in catarrhal affections, attended as they usually are with inflam- 
matory symptoms, cannot be too severely censured. Let me 
refer you to a very sensible letter on this subject, in which the 
folly of relying upon syrups and expectorants, in pulmonary 
complaints, has been very fully exposed. It is a letter written 
by the celebrated traveller Dr. Moore. (See his Travels in 
Italy.) The elder Dr. Bard made it the duty of every one of 
his private pupils to transcribe this letter, so sensible was he of 
the important instruction it conveys. Mercury, as I have before 
remarked, should never be employed in the second stage of 
phthisis. Dr. Cullen justly remarks, that it is manifestly hurt- 
ful. He should have excepted its effects in cases where it is fol- 
lowed by salivation, but which it is difficult to obtain in the ad- 
vanced stage of phthisis; the use of mercury, therefore, should be 
restricted to the first stage of this disease. One word upon the 
diet of the patient, for in this stage of the disease the diet of the 
patient should receive the special attention of the physician, for 
much may be accomplished frequently by the nourishment that 
may be directed at this time. 

In the inflammatory stage cf phthisis, you will recollect, we 
enjoined the strictest abstinence ; but, at this time, our object is 
to build up the system, and to counteract that waste which it un- 
dergoes by the discharges that now constantly expend its powers. 
With this view the most nutritious food is now to be directed. By 
this I mean such food as contains the greatest quantity of nutri- 
ment in the least compass, and which too shall produce the least 
temporary excitement. Yet I have seen an exception to this, in 
the case of Mr. C. I have seen beef-steaks with cayenne pepper 
made use of, and without evil consequences, even after his hemor- 
rhage from the lungs. The best articles of nourishment in this 
stage of the disease are eggs, either given raw, mixed up with 
metheglin, or they may be taken soft-boiled, say three minutes. 
Rule for boiling eggs: — Put them on the fire in cold water; when 



PHTHISIS PULMONALIS. 591 

the water begins to boil, the eggs are sufficiently done, and that 
throughout. Or the egg may be given in custards — two, three, 
or four, to a quart of milk. You may now allow oysters ; the 
testacea in general; even snails in milk; isinglass in milk, in the 
preparation called blanc mange. Milk is also among the best of 
the nutrientia; in case of heart-burn or aphthous ulcerations, it 
should be given with lime-water; jellies; turtle soup, mock or 
real You may now allow animal food in general, particularly 
venison, wild fowl, done rear, so that the juices of the meat are 
not dissipated by the fire. In like manner, make use of vegeta- 
ble nourishment abounding in mucilage; rice, boiled to a jelly; 
arrow root, maranta arundinacea; sago, cycas circinalis et revo- 
luta; tapioca, jatropha manihot; rye, made into mush with milk; 
chocolate; lichen islandicus. Dr. Good believes the lichen cocci- 
ferus, and lichen pulmonarius, and the Pyxidatus or cup moss, have 
the same qualities. The effect of the Iceland moss is to allay 
cough and diminish fever, and like the hop, it is supposed to 
possess some sedative power. Willis recomends it in hooping- 
cough ; Stroeck in hectic fever generally. You may also give 
malt liquors, as porter and ale; but carefully avoid wine, spices, 
and spirituous liquors, for they readily light light up the fire, 
especially if it has not been perfectly extinguished. The earth- 
bath, or banos de tierre of Solano de Luque, has been also extolled 
in Spain and England among the remedies for consumption. Van 
Swieten tells us this is a common practice in Grenada, in Andalu- 
sia, and other parts of Spain ; in England it was first made use of 
by the celebrated Dr. Graham, who introduced the celestial bed, 
into which any woman that entered was got with child. He cer- 
tainly could not introduce a more popular patent into the city of 
London ; he was accordingly very much employed in the fashion- 
able circle ; old and young all had recourse to the doctor's bed. 
It reminds me of a late surgeon of this city, not remarkable for his 
moral rectitude, though he stood well with the ladies, that he never 
had any difficulty in curing dysmenorrhea, and in removing bar- 
renness in those ladies who would place themselves under his pre- 
scriptions. But with regard to the earth-bath, I would only re- 
mark of it that it is but a little anticipation of what the patient 
may soon expect to take place, if this prescription be persisted in. 
Van Swieten however, approves of it, and it has been since re- 
commended by Dr. Simmons and by Pouteau. Dr. Beddoes in- 



592 LECTURE XLVIII. 

troduced a new theory, that consumption of the lungs consisted 
in and was kept up by an excessive quantity of oxygen, and that 
the disease was to be removed by abstracting a portion of the 
oxygen. Various gases were accordingly prepared, and in some 
cases the patients were sent to the vats of the breweries, to re- 
spire an air abounding in carbonic acid gas. With the same view, 
in Holland and Germany, it has also been fashionable of late to 
put the patient in a horse or cow stable, for the purpose of breath- 
ing an air that contains less of that stimulant ingredient oxygen, 
or rather which contains more carbon ; for by respiration, the air, 
having lost a portion of its oxygen, is reduced to the state of hy- 
drocarbonate. With the same view it has been recommended 
to ladies to make bed-fellows of their dogs and their cats. Dur- 
ing the existence of this delusion, I occasionally met with patients 
desirous of an experiment. Matrimony, we well know, especially 
when pregnancy follows, has changed the current very success- 
fully in this disease ; so also has mania, and probably upon the 
same principle, cured phthisis. Mineral waters, too, are frequent- 
ly resorted to in this disease. Those abounding in iron are occa- 
sionally useful in the second stage, as tonics, except in cases of 
hemoptysis, or those in which a tendency to it exists; in the first 
stage they are totally to be prohibited; in the second, at proper 
seasons of the year I have recommended my patients to visit 
Ballston; the journey and agreeable society are sometimes bene- 
ficial, but the waters should be cautiously directed in this dis- 
ease. Such cautions I have pointed out in a paper on that sub- 
ject and Ballston water. (See Register. See also my Appendix 
to Thomas, new edition. See also my Essays.) 






593 



LECTURE XLIX. 



CYNANCHE TONSILLARIS— VEL TONSILLITIS. 

We now enter upon the consideration of the various forms of 
cynanche, so denominated from the sharp coughing and sense of 
strangling that attend upon these affections of the throat 

Cynanche is a term composed of two words having a reference 
to these effects, viz. xvov, a dog, (the acute cough bearing some re- 
semblance to the barking of that animal,) and the verb ay^co, to 
strangle. The first we shall notice is the cynanche tonsillaris, 
or tonsillitis, as it may more properly be called. Dr. Cullen's de- 
finition is as follows : " Cynanche tonsillaris membranam faucium 
mucosam, et precipue tonsillas, tumore, et rubore afficiens cum 
febre synocha. " He should have added to this what he has added 
to his definition of cynanche in general, viz. dolor faucium; de- 
glutitia difficilis, cums angustiae in faucibus sensu; for these last 
mentioned symptoms are more characteristic of this form of 
cynanche than any others; in some of them they are wanting 
altogether; indeed it is a remarkable circumstance attendant on 
croup, that it is attended with no difficulty of swallowing. But 
in another particular Dr. Cullen is not sufficiently explicit, when 
he confines this inflammation to the mucous membrane, for 
cynanche tonsillaris, when it is thus locally confined not only 
affects the mucous membrane, but the very substance of the 
tonsils themselves, and not unfrequently ends in abscesses, and 
sometimes sphacelus of those organs; first affecting one of them, 
afterwards the other, and in some cases the tumor is so great that 
the tonsils meet, insdmuch that you see nothing of the uvula. 
But the inflammation is not confined to the tonsils, it extends 
also to the velum pendulum palati, involving the muscles of the 
51 



594 LECTURE XLIX. 

pharynx, the constrictor isthmi faucium, and the uvula, which is 
elongated, irritates the muscle just before mentioned, producing a 
continued effort to swallow, and attended in some instances with 
very acute distress. The tumor of the tonsils is sometimes so 
great that it becomes perceptible to the eye externally; in all 
cases they are to be felt in the throat, adjoining the angles of the 
lower jaw. Sometimes, too, the inflammation spreads itself into 
the pharynx and oesophagus; it is then more dangerous; in other 
cases it extends through the eustachian tube even to the ear, 
affecting that organ not only with severe pain but deafness. 
When it is thus extensive it goes still further; the muscles upon 
the whole side of the head become affected, and are especially 
painful upon motion; the eyes, the face, the ears, all partake of a 
general fulness and sense of soreness; the external muscles of the 
head and neck become so much affected that it is difficult and dis- 
tressing even to turn the head upon the shoulders; the whole 
system becomes more or less affected; and, indeed, from the 
commencement the symptoms of general irritation show them- 
selves in connexion with the local affections of the throat; the 
patient is affected with chills; an excited pulse, which is both 
frequent and hard, though less so than in many other inflamma- 
tions which are situated in more dense membranes; the tongue 
is furred and white, attended with great thirst and sliminess 
about the mouth, and a general interruption, I may say, to all the 
excretions. This disease attacks most frequently those who are 
full habited and of nervous temperament; that is, such as have 
abundant secretions flowing, and great sensibility to those causes 
which will shut them up. For the same reason females are more 
subject to this disease than males, and children more than adults. 
Like the other phlegmasia^ it is most prevalent in autumn, spring, 
and winter; but it rarely occurs in the summer season, except 
where a person much heated may be exposed to a stream of air; 
it is also more prevalent in moist situations, and on the seaboard 
where the vicissitudes of weather are most frequent and most 
severe. The natural termination of this disease, as it is seated in 
a secreting surface, is most usually by resolution; sometimes it 
affects the cellular matter of the tonsil, and proceeds to suppura- 
tion ; it rarely ends in gangrene, never in scii rhus, but it is apt 
to leave a very turgid and permanently enlarged state of the 
tonsils, and which indeed sometimes calls for removal by the 



CYNANCHE TONSILLARIS. 595 

knife or ligature; but this enlargement only occurs after very 
repeated attacks, and after gross neglect either on the part of the 
patient in not early applying for medical advice, or temporising 
feeble practice in the doctor, when he may be called upon to 
prescribe. The predisposing causes are 1st. a relaxed full habit 
of body. Hence plethoric females who live a sedentary life, and 
perhaps confined to a warm room, are most susceptible of this 
disease when exposed to cold; 2d. the practice of foot-bathing in 
warm water; 3d. the relaxation of the throat by the use of mer- 
cury also prepares the patient to become readily affected by cold; 
4th. keeping the neck very warm by much covering is another 
cause well calculated to invite an attack; 5th. the debility of the 
parts by a former attack renders such person very liable to a 
renewal of the disease upon the least exposure to the usual ex- 
citing causes. Mrs. T. every year suffers a severe attack, and 
which for the most part ends in abscess. A daughter of Gen. M. 
in like manner is very subject to the same disease, and which, too, 
usually proceeds to suppuration; that is, the whole tonsil, as well 
as its mucous membrane is equally susceptible of inflammation; 
and hence too, you will find, that those who once have the sup- 
purating sore-throat become very subject not only to this disease, 
but to this very termination of it upon every attack. 

The exciting causes are cold, changes from a hot room to the 
cold air. I have had repeated attacks of sore throat after visiting 
the hot-house at the botanic garden. Change of dress; a partial 
stream of air. 

In the treatment of this disease, we should be governed by its 
different stages. In the 1st. or forming stage, the indication is to 
restore the excretions, which are diminished; especially those of 
the tonsils and fauces. An emetic at this period, as in croup, is 
particularly useful, and will frequently, in a few hours, put a 
period to the disease, especially in children, whose secretions are 
easily unlocked by the relaxing effects of nausea and vomiting, 
especially in the first stage of the disease. In the full habit of 
body, and in old age, they must be given with caution, and not 
until venesection and a purge have been administered. But where 
no remarkable fulness or determination to the brain forbids their 
use, they will be employed with the best effect. This practice 
but ill accords with that recommended by Dr. Cullen, and Thomas, 
and Good, who prescribe without discrimination, as to the stage 



596 LECTURE XLIX. 

of the disease, the use of an astringent gargle, consisting of oal 
bark and alum; an infusion of rose leaves and elix. vitriol — acid 
and astringent gargles. 

But, 2d. When inflammation is actually formed, the tumour of 
the parts considerable and increasing, the patient, too, of a full 
habit of body, your indication is by every means in your power 
to cut off the supply of blood to the part. This is to be effected 
by large and repeated bloodletting; the blood should be drawn, 
too, from a large orifice, so as at the same time to relax the sys- 
tem as much as possible, by the suddenness with which it is 
drawn, as well as quantity. Local bloodletting, by the lancet or 
scarificator, or by leeches, should also be employed, especially in 
those cases where it usually proceeds to suppurate. Cathartics, 
calomel and jalap; or calomel alone, which is preferable; glauber 
salts; antimonials; cream of tartar; sp. mind.; calomel and anti- 
mony. Liniment to the throat, composed of two parts aq. am- 
mon., one of oil. Blisters to the throat, if the swelling is consi- 
derable, are also useful by translating the irritation to the surface. 
Warm bathing and foot-bathing, will also contribute to promote 
the effects of these medicines upon the excretions. The steam of 
warm water and vinegar may also be applied to the throat. But 
let me advise you to avoid the common but improper practice of 
gargling in the first stage — it aggravates the inflammation by the 
exertion of the muscles of the throat employed in that process. 
When actual ulcers are formed gargling is necessary; and it is 
probable that the use of it in this state of the throat, has led 
many to employ it in the first stage, misled by the exudations of 
lymph or mucus which appear in that stage, and which many 
persons, unacquainted with the nature of it, consider to be real 
ulcers; whereas, they are the mere effusion of the viscid matter 
from the inflamed vessels. But when this disease may be pro- 
ceeding to suppuration, and this is unavoidable, a gargle may then 
be used with advantage. That which is usually employed, con- 
sists of sage tea, vinegar and honey— a gargle of an infusion of 
hops, or of barley-water Ifci.; and sal ammoniac, £ij. But 
that which I have directed with most benefit, and which I 
have found best calculated to hasten the suppurative process, is a 
strong decoction of figs, aided by a large bread and milk poultice, 
or a hop poultice, applied to the throat. 

But, 3d. When suppuration has taken place, discharge the 



CYNANCHE TONSILLARIS. 597 

matter as soon as possible; for the parts are of so lax a texture, 
that the tumor will remain stationary, or perhaps go on to increase 
for several days, if not relieved by the lancet or scarificator. 
Should the patient be very much irritated, and altogether unable 
to swallow nourishment, it must, in this case, be administered by 
the bowels; for this purpose, injections of soup or milk, or milk- 
punch, gruel, sage, &c. should be thrown up twice or three times 
a day, to secure their retention. But the patient is not only 
affected with difficulty of swallowing, but also of breathing. 
Bronchotomy, however, can never be necessary in this disease; 
yet you find it recommended by Thomas, and to be early per- 
formed. Dr. Cullen, in his long practice, never had occasion to 
see a case of this disease requiring this operation; nor will you, 
probably, ever meet with one — I have met with none. 

4th. In some instances, you are not called upon in the first 
stage of the disease; and instead of the terminations we have 
mentioned, the disease has ended in ulcerations of the throat. I 
mean those usually attendant upon cynanche maligna, exhibiting 
a livid ash colour, attended with a very offensive foe tor. In that 
case, a gargle of yeast, water, and honey, with the addition of 
borax, or vinegar, water, and honey, should be employed. But 
this termination we shall have occasion to notice more particu- 
larly when speaking of cynanche maligna, 

In the passive stage of the tonsils, use gargles of port wine, the 
decoction of oak bark and alum; oak bark with vitriolic acid, or 
muriatic acid — scarifications should there be tumors of the tonsils. 

The diet should be abstemious in the first stage, as in the active 
stage of the phlegmasia^ in general. 

Drinks. — Barley-water; teas; toast-water; fruits in water; 
currant-jelly; apple-water, &c, until inflammation be removed — 
then better food, adapted to the degree of debility; another con- 
dition of body must be directed, to prevent a return of the dis- 
ease. Let your patient be directed to abandon the practice of 
bathing the feet with warm water, for the feet are thereby made 
doubly sensible to cold, and in this way, I believe, sore throat is 
frequently induced. Another inconvenience attendant upon this 
practice, is that the feet and legs are thereby rendered very cold; 
and indeed, in some instances, it is an actual source of distress, 
depriving persons so affected of their sleep. When called upon 
to prescribe for cold feet and limbs, as you will be, recommend 
51* 



5&8 LECTURE XLIX. 

the practice of washing the limbs with a napkin, dipped in cold 
water; and afterward diligently rubbing them with a coarse cloth. 
A glow instantly follows. Let them avoid also the practice of 
inclosing the throat with much flannel, or the fashionable poul- 
tices of cotton, or those made up of the doubling of several 
neckcloths; for those warm coverings of the throat, by the relax- 
ation they occasion, render those parts much more liable to in- 
flammation than they otherwise would be. On the contrary, a 
more free exposure of the neck, and the daily practice of washing 
the throat, internally and externally, with cold water, I believe 
affords the best security against the returns of this disease. 

The removal of the tonsils by the knife is preferable to liga- 
tures or wires. There is no necessity for the delay of removing 
them by wires. There are no vessels of much importance to be 
divided. (See Paper by Alex. E. Hosack, in the Med. Journal 
of Philadelphia,) who was the first in this country to remove 
them by the knife. He has done it six times, and no hemorrhage 
has followed. 



Mtt 



599 



LECTURE L. 



CYNANCHE MALIGNA, 

Cynanche maligna, the putrid or ulcerous sore throat. This 
is a much more formidable disease than the preceding, and calls 
for your particular attention, inasmuch as the more malignant 
symptoms which characterize it frequently appear very early in 
the disease. Dr. Cullen defines the disease as follows: "Tonsil- 
las et membranam faucium mucosam afficiens, tumore, rubore, et 
crustis mucosis coloris albescentis vel cineritii, serpentibus, et 
ulcere tegentibus ; cum febre typhode et exanthematicis." That 
it affects the tonsils and mucous membrane of the fauces with tu- 
mor, redness, and mucous crusts, of a whitish or ash colour, 
spreading or covering ulcers* attended with a typhoid fever, and 
with exanthemata, i. e. with more or less of a rash upon the body, 
assuming frequently the appearance of petechias. The symptoms 
in the very commencement of this disease are very similar to 
those of the cynanche tonsillaris: the first stage of excitement 
however, is but of short duration, yet it is much more severe ; 
the operation of the poison is such upon the nervous system, that 
it very soon prostrates the vital powers: analogous to some other 
contagious disease, it in some cases affects the vital functions, from 
the very commencement of the disease, manifesting itself in a 
feeble circulation, and great anxiety and depression of spirits. 
For the most part the symptoms which more immediately desig- 
nate the malignity of the disease, do not disclose themselves until 
two or three days have elapsed; then the ash coloured spots ap- 
pear on the throat, attended with fcetor and other evidences of a 
typhoid state of the whole system; yet in some instances I have 



600 LECTURE L. 

seen these very symptoms show themselves in the first twenty- 
four hours, and prove fatal upon the second day of the disease. 
The poison of the disease, before the fever is excited, has been 
operating both upon the fluids and upon the nervous system, pro- 
ducing a change in the condition of the former, and by its dele- 
terious operation, analogous to other poisons, prostrating the 
powers of the latter. 

Hence you see the dark purple, crimson, or lurid colour of the 
throat, the ash coloured exudation, the foul spreading ulcer, fol- 
lowed by the early gangrene and sloughs of the tonsils, with 
an offensive breath. Hence, too, the hemorrhages from differ- 
ent parts of the body — hemorrhages from the nose, from the 
throat, tongue, lips, blistered surfaces, bowels; the petechia,* 
the blotches, the offensive excretions, the discoloured tongue, 
teeth and lips, that characterise the progress of this complaint. 
From the same causes you are led to explain the early debility, 
anxiety, and depression, and the small and fluttering pulse, and 
indeed, which is feeble almost from the commencement. In some 
instances the inflammation and ulcer spread themselves to the 
neighbouring organs, affecting the eustachian tube, and even de- 
stroying the texture of the ear and the powers of hearing. Some- 
times the parotid and the chain of glands situated on the neck 
partake of the disease ; but in other instances a still more formida- 
ble extension of disease shows itself; that is, the acrid matter and 
ulceration affect the roof of the mouth, the palate, the pharynx, 
oesophagus, and stomach, and ends in a disorder of the bowels 
and a fatal diarrhoea. In other instances again, the same peculiar 
inflammation and ulcer travel down the trachea, producing symp- 
tomatic croup, or cynanche trachealis. (See Dr. Bard's excellent 
Dissertation on this disease as it prevailed in this city many years 
since. Am. Phil. Trans.) Dr. Cullen refers to this dissertation 
in his nosology, under the head of cynanche maligna, which is its 
proper place; the symptoms of croup being not primary, but 
symptomatic. 

This disease terminates its course usually in about five or six 

* The rash that frequently attends a typhoid state of body, and which appears 
in this species of cynanche, has led to the question so much and so violently agi- 
tated, whether this malignant form of cynanche be not scarlatina anginosa — 
whereas they are as distinct from each other as the malignant yellow fever from 
the common domestic bilious remittents of the United States. 



CYNANCHE MALIGNA. 601 

days; in that time it either proves fatal, or the patient is conva- 
lescent. There is, therefore, no time to be lost, and it calls not 
only for all your activity, but all your powers of discrimination. 



CAUSES. 

Sometimes this disease is a continuation of cynanche tonsillaris 
long protracted. This is a rare occurrence, and is seen only 
when a certain condition of atmosphere has been favourable to 
such malignancy; but from whatever cause it may have origi- 
nated, it is afterwards propagated by contagion, and in its cha- 
racters, bears the same relation to cynanche tonsillaris, that in- 
fluenza does to catarrh from cold, and peripneumonia typhodes to 
inflammatory pneumony, dysentery to simple enteritis, or conta- 
gious puerperal fever to simple hysteritis. 

The treatment of this disease should be active in proportion to 
its malignancy, and the rapidity with which it passes through its 
various stages. Its first stage of excitement, as before remarked, 
is short, but frequently equivocal, not decidedly or exclusively 
inflammatory, but frequently showing its peculiar malignancy 
very early. The means of reducing the excitement must there- 
fore be had recourse to with a cautious hand. Venesection must 
either be omitted altogether, or only employed under peculiar 
circumstances, as in a full athletic habit, and when the inflamma- 
tory symptoms are more strongly marked than in ordinary cir- 
cumstances; it is accordingly very rarely called for, and is gene- 
rally considered as a fatal practice. In ulcerous sore-throat the 
same caution is necessary in the use of purgatives; for even 
where spontaneous purging appears early in the disease, it is con- 
sidered as a dangerous symptom; the milder cathartics and ene- 
mata are therefore usually recommended, and have been highly 
extolled in this disease. Calomel was employed on Long Island 
with the greatest success in this disease, before the American Re- 
volution, by the late Dr. Ogden ; by him I believe it was origin- 
ally introduced. The introduction of this treatment is however 
due to our own country. It was given in large and repeated 
doses, and usually conjoined with opium, to secure its general 
effects upon the system and to prevent its too free operation upon 
the bowels. Emetics are also important remedies in the com- 
mencement of this disease. By their effects on the excretions gene- 



602 LECTURE L. 

rally, and thereby their alterative operation upon the whole sys- 
tem, they take off much of the violence of the complaint, and 
save the vital functions from injury. Sudorifics, viz. wine whey, 
snake root, or sage tea, warm bathing, fomentations, for the same 
reason, are useful, and are accordingly indicated, after the use of 
emetics and purgatives, but they should be of the stimulant kind, 
not even antimonials or spirit, mind. Blisters, too, are of doubtful 
efficacy, and should only be employed in the very first stage of 
the disease, and then only for the relief of particular symptoms, 
especially for the relief of the throat; as general febrifuge reme- 
dies, they are certainly dangerous applications in cynanche malig- 
na. Besides the use of snake root and wine whey, the general 
tone of the system must be preserved, by the early use of bark,* 
and wine, and porter, with the best vegetable nourishments, as 
sago, arrowroot, panada. Remember, as in typhus fever, animal 
food should be totally proscribed; for the same reasons that vege- 
table diet is called for, the patient may take moderately of the 
acid fruits, especially fresh fruits, duly guarding however against 
their purgative effects. What local remedies shall be made use of 
to diminish the inflammation and tendency to gangrene, and after- 
wards to remove the sloughs which may form, and to excite the 
parts to a healthy action? In the first stage make use of a gargle 
of vinegar, water, and honey, or rather let the patient inhale the 
steam or vapour of these ingredients from Mudge's inhaler, or 
from the inverted funnel. When the ash-coloured crusts and 
ulcers appear, or the dark crimson colour, threatening gangrene or 
sphacelus, manifests itself, the yeast gargle, with an addition of bo- 
rax and honey, is preferable. Others, however, prefer a decoction 
of the bark, with the addition of myrrh and the muriatic acid. 
Reich's prescription is now useful, viz: Jfc. decoct, cort. Peruv. §vj.; 
muriatic acid 3i.; tinct. myrrh, gi.; tinct. aromatic gss. M.; to beused 
as a gargle. Some again make use of port wine, others of brandy 
and water, as a gargle; some touch the parts with a solution of the 
white vitriol ; others use the blue ;t while others again prefer the 

* When children are the subjects of cynanche maligna, and you may find diffi- 
culty in giving the bark, it should be administered by injection, and which should 
be had recourse to the moment the first excitement is diminished. 

f When hemorrhage takes place from the throat, the sulphate of copper is cer- 
tainly a necessary prescription, or the Ruspini's styptic may be employed, which 
has vitriol as its base, at least its most active ingredient. 



CYNANCHE MALIGNA. 603 

acetate of copper, in the form of the mel. Egyptiacum of the dis- 
pensatory. The late Dr. Anderson, a very eminent physician 
from the island of Jamaica, when on a visit to this city before his 
return to Europe, informed me that it had become the most gene- 
rally approved practice in the West Indies, to make use of the 
cayenne pepper in the form of a gargle, as well as internally, and 
that it effected a change in the state of those ulcerated surfaces 
more readily than any other means he had ever seen prescribed. 
The following is the formula I received from him: Two table- 
spoons full of the small red pepper, or three of the common; two 
tea-spoons full of salt; mix into a paste; add ^viij. of vinegar and 
gviij. of boiling water; of this they also gave the patient one 
table-spoonful every half-hour, besides making use of it as a gargle 
to the throat. But this, I find, is the prescription of Mr. Stewart, 
w T ho first introduced the use of this medicine in cynanche maligna. 
(See Med. Commentaries, 1 2th vol.) Dr. Thomas also states, that he 
has used it with success in his practice while resident in the West 
Indies. But, as I said before, my chief dependence is upon the 
yeast, borax, and honey, as my local application, with a solution 
of the sulphate of copper, or lunar caustic, occasionally to touch 
the parts before using the yeast gargle. In children, cleanse the 
throat by a piece of sponge, attached to a small piece of stick or 
whalebone, or the common swab of linen. This is necessary, as 
the children swallow this acrid matter, and it renders the disease 
more dangerous; the greater fatality of this disease in children is 
partly ascribed to this circumstance. As this is a contagious dis- 
ease, be careful to separate the well from the sick ; and in the 
sick room make use of every means of diluting the atmosphere, 
and of correcting any vitiation that may have been produced by 
want of cleanliness. The antiseptic fumigations, by means of the 
sulphuric, the nitrous, the muriatic, or the acetous acids, are now 
called for; in a word, the same treatment as in typhus should be 
pursued. 



604 



LECTURE LI 



PERITONITIS. 



Inflammation of the membrane lining the abdominal cavity, 
and covering the abdominal viscera, so denominated from 7tspi- 
tsivca, to extend around. Dr. Cullen defines it thus: "Pyrexia; 
dolor abdominis, corpore erecto acutus; absque propriis aliarum 
phlegmasiarum ahdominalium signis." This disease is rarely so 
confined; yet it certainly, in some instances, originates in the pe- 
ritoneum, as from wounds; and in a case under my care, it arose 
from cold; but for the most part when so originating, unless it be 
soon relieved, it extends to the neighbouring organs, affecting the 
stomach, intestines, omentum, the mesentery, &c Dr. Cullen 
distinguishes it into three species, the 1. propria,* 2. omen- 
talis, and 3. mesenterica. This distinction it is impossible for 
us to adopt, and it is altogether useless. If any species be made, 
take in all the abdominal viscera, and not merely the omentum 
and mesentery, for the other viscera are all just as likely to be- 
come affected as those noticed by Dr. Cullen. But who can dis- 
tinguish them ? and what practical good can it lead to ? If any 
division be made with this view, let it be into idiopathic and 
symptomatic. Such a distinction I have adopted; for it may be 
observed that not only the inflammation when originally or pri- 
marily seated in the peritoneum (from whatever cause) readily 

* Affecting the peritoneum, strictly so called, or lining- of the belly within, as dis- 
tinct from those extensions of it that involve the different viscera. Cullen him- 
self, observes, that it is difficult to say by what symptoms they are to be known, 
and that when known, they require but the remedies for inflammation in general 
These species, therefore, should not have been in Cullen's nosology. 



PERITONITIS. 605 

extends to the different viscera; but, vice versa, any of the abdo- 
minal viscera being in an inflamed state, the peritoneum soon par- 
takes of it, more especially if it begins in the uterus, in which, on 
account of its great sensibility, the inflammation is rapid, violent, 
and readily involves the neighbouring organs. In some cases it 
appears as a general soreness, not referring to any particular organ, 
and though sometimes it occurs after delivery, the uterus is not 
always the part first affected, even though the labour may have 
been violent, tedious, and mismanaged; though the patient in the 
course of labour may have been excited by heating spirituous 
drinks, or the subsequent application of cold ; the peritoneum and 
not the uterus, even in this case, may be the primary seat of dis- 
ease. I have, therefore, given it a distinct place from an inflam- 
mation of the womb, or puerperal fever. In the case, too, above 
referred to as arising from cold, it preserved its appropriate cha- 
racter as distinct from gastritis or enteritis. In that case it arose 
from change of clothes — the hot air of the assembly room after 
exposure to cold, and perhaps his wine and whiskey punch as 
well as the exercise of dancing, may have had their agency in 
giving a preternatural excitement to the system. Seeing, then, 
that this disease has its peculiar character and its appropriate 
symptoms, I have given it a distinct place in our arrangement. 
The symptoms are, chills, soreness of the abdomen, soon becom- 
ing acute, the very weight of the bed-clothes becomes painful, 
followed by pure unmixed synochal fever; pulse small, corded, 
and frequent, " sometimes perfectly natural, in others strong and 
full, as in pneumonia; again, in others, small, feeble, fluttering, 
and almost imperceptible." (Bedingfield, p. 211.) Respiration 
corresponds with it; heat for the most part increased, excepting 
perhaps the extremities; tongue white and furred; countenance 
pale; the blood being determined to the membrane the more im- 
mediate seat of the disease, and probably to the viscera of the 
abdominal cavity generally. The patient lies on his back, his 
lower extremities drawn up to relax the peritoneum; in that situ- 
ation, too, the viscera are less pressed upon, and they occasion 
least irritation to the inflamed membrane; great swelling of the 
abdomen manifests itself, especially in puerperal cases of perito- 
nitis. The stomach and bowels, in some cases, soon partake of 
the inflammation; the stomach becomes irritable, excessive vom- 
52 



606 LECTURE LI. 

iting comes on, and that oftentimes bilious, owing to the great 
determination to the abdominal viscera. For the most part, cos- 
tiveness and spasms of the intestines; but sometimes diarrhoea is 
the effect of the great biliary discharge into the intestines; for the 
intestines are not now affected with stricture as when they are 
the original seat of inflammation. The bladder also, is irritated, 
and contracts, frequently; small quantities of high coloured urine 
are discharged, the kidneys, like the liver, having an inordinate 
current of blood running through them. It is a general remark, 
that very high coloured urine is always, or very generally, attended 
with increased inclination to pass it, and even in small quantities, 
because it is more acrid. It comparatively partakes of the blood 
from whence it has been separated, and abounds in all the saline 
properties of the blood itself. You will recollect that as it regards 
the blood, an error loci always affects the parts in which such 
blood may be effused. The blood effused in the lungs produces 
violent coughing — in the uterus, excites to contraction and pain 
— blood poured into the stomach produces vomiting — in the in- 
testines, diarrhoea — in the gall bladder, excites vomiting and 
purging — in the bladder, a propensity to micturition. The 
swelling of the abdomen increasing, it becomes more painful; 
respiration becomes oppressed by the tumour necessarily pressing 
up the diaphragm, the secretions are all checked ; the pulse increas- 
ed to 120 or 130. In a few days, nay, in a few hours, if not relieved, 
a total and sudden cessation of pain follows; the swelling of the 
belly increases; the countenance becomes livid; the extremities 
become cold; profuse sweats follow, all showing sphacelus to have 
taken place — involuntary evacuations by stool and urine take 
place. The vital principle is sensibly impaired, showing its loss 
in delirium and convulsions, which are soon followed by dissolu- 
tion. Upon examining the body after death the same swelling 
which had appeared a few hours before dissolution is now sud- 
denly augmented — the abdomen is now inordinately distended 
and tense as a drum, and upon opening into the cavity of the 
belly there is a sudden extraction of a gas, foetid and offensive in 
the extreme. Upon exposing the viscera, a large purulent and 
serous effusion is found floating over the surface; exudations of 
newly formed gelatinous matter having the appearance of mem- 
branes appear to glue the viscera together, they are frequently 



PERITONITIS. 607 

found adhering to each other, showing a highly injected state of 
the vessels; in some portions displaying the gorged condition 
of parts constituting gangrene and in others the total decomposi- 
tion called sphacelus. 

But again, when the patient has been actively treated in the 
commencement of the disease, and experiences relief from the 
urgent symptoms, and evidences of a favourable termination of 
the disease show themselves, they are the following: the pulse 
becomes full and soft; the tongue moist; the respiration natural; 
the belly soft and without pain on pressure; the milk and lochia 
are restored; the skin moist and warm; the excretions in general 
are restored and natural, with a return of blood to the face and 
extremities; blistered surfaces assume a healthy red colour; the 
sleep is natural and refreshing; the mind tranquil and composed. 
The predisposing causes are a sanguine habit of body, and disten- 
sion of the belly by pregnancy or by dropsy. The exciting causes 
are cold suddenly suppressing the excretions; injuries during par- 
turition; a lingering labour ; exciting drinks during parturition, 
or immediately after child-birth; the wound in tapping for dropsy, 
or in the operation for hernia, or for aneurism; the operation for 
hydrocele sometimes excites peritoneal inflammation: in like 
manner a mismanaged inflammation of the testis sometimes ex- 
tends to the peritoneum. The excitement of fever is, in some 
cases, thrown in upon the belly, by check of perspiration, and 
produces peritoneal inflammation. 



TREATMENT. 

Venesection should be used until the pulse rises. The physi- 
cian should not be deceived or deterred by the small pulse and 
paleness of countenance. There is related a case by Beding- 
field in which two hundred and forty ounces were drawn be- 
fore the patient was relieved, besides covering the abdomen 
with leeches, his general practice. Emetics large and repeated 
should be given; the warm bath, general and partial, should be 
used, with fomentations of vinegar and water to the belly; but 
after the application of a blister to the belly, fomentations should 



608 



LECTURE LI. 



be applied to the extremities. Saline 

freely administered, as also small doses 

mony, 

may in some cases 



cathartics should be 

of calomel and anti- 

unless the stomach be disturbed. The Dover's powder 

be called for. Repeat the enemata frequent- 



ly. Let the drinks be gruel, toast-water, barley-water, gum ara- 
bic, milk and water. 



609 



LECTURE LII 



GASTRITIS. 



Gastritis, or inflammation of the stomach, so called, from 
yas^P, the stomach. Dr. Cullen calls it a " pyrexia typhodes." 
Why is it so called ? Is it because the pulse is small ? or from 
its tendency to sphacelus ? or on account of the nervous affections, 
the prostration and rapid exhaustion which so soon supervene ? 
This last is most probable. The remainder of Dr. Cullen's defi- 
nition runs thus : " anxietas in epigastrio, ardor et dolor, ingestis 
quibuslibet auctus; vomendi cupiditas, et ingesta protinus rejec- 
ta; singulus." I have divided it into idiopathic and symptoma- 
tic; that is, the first primarily appearing and originating in the 
stomach; the second communicated to the stomach after appear- 
ing in other parts either of the intestinal canal, or in some of the 
adjacent viscera, or as symptomatic of fevers. Thus we see it to 
be symptomatic of aphthae, of peritonitis, enteritis, hepatitis, hy- 
steritis; symptomatic of yellow fever and of the suppression of 
small pox. These two species may each also be subdivided in the 
manner Dr. Cullen has divided it, into inflammation of the phleg- 
monoid kind, involving all the coats of the stomach, and of the 
erythematic, in which the inflammation is confined to the nervous 
or villous coat of the stomach, and is attended with milder symp- 
toms, in all respects such as we see frequently to succeed to 
aphthae and erysipaletous affections of the fauces, or derangement 
of the digestive powers of the stomach, attended with fermenta- 
tion and a predominent acidity, or a slight degree of fever, &c. 
Dr. Cullen very properly associates the soreness of the mouth 
with the affections of the stomach. In this erythematic form of 
52* 



610 LECTURE LII. 

gastritis the fever and pain are both moderate, the last not in- 
creased upon pressure: on the contrary in the phlegmonoid gas- 
tritis, in which all the coats are affected, the fever and pain are 
both much more violent. Dr. Cullen, in a note, remarks that 
this is a just distinction, yet sometimes difficult to be discerned. 
I have frequently seen them both. I have seen it attendant upon 
phthisis, beginning with aphthae in the mouth and fauces, and 
subsequently affecting the oesophagus and stomach. In like man- 
ner it sometimes succeeds to the inflammation in the mouth from 
teething. (See paper by Dr. Trenor in the Medical and Physi- 
cal Journal of New York.) I have also seen it as attendant upon, 
and the sequela of yellow fever, but in which it was confined to 
the nervous coat of the stomach, or its mucous lining. This dis- 
tinction is to be made with great caution, especially as it regards 
practice; in cases of doubtful character we had better err in too 
active treatment where there is no danger, than by too passive 
conduct where there is. The symptoms, more especially in the 
phlegmonoid form, are — the pulse small, frequent, and corded; the 
tongue white and furred; great pain, especially on pressure, with 
a sense of burning; great distress; severe spasms, and sometimes 
convulsions. In some eases I have seen the disease attended 
with involuntary efforts to bite the by-stander, or any thing near, 
as the cup or glass in which his drink is offered him, exhibiting 
all the fury of perfect hydrophobia. I once saw a case in which 
the disease was induced by drinking cold water when heated. 
So severe were the spasms of the poor man that he crushed the 
tumbler in which his drinks were presented to him. Such is the 
sensibility of the stomach, derived from its numerous nerves, and 
the great semilunar ganglion, that all these violent symptoms are 
to be expected. Nor are they so confined; the irritation extends 
to the sensorium, producing the symptoms of an inflamed brain. 
I have seen several cases of persons arriving in this city poisoned 
by eating fish caught on the copper banks. Ten or twelve were 
so severely affected, that Dr. Bayley, after the death of one or 
two of them, examined the head, looking for inflammation; so 
intimate is the connexion between the head and stomach. I am 
not surprised at the error of Clutterbuck in ascribing so much to 
the brain as he has done, nor indeed can we wonder at the folly 
of Broussais, in tracing all the phenomena of disease to the 
stomach, or others to the different tissues. Delirium and hiccup 



GASTRITIS. 611 

appear early in gastritis, as in diaphragmitis, and for the same 
reason. Upon another occasion I was called to see a gentleman, 
ill of gastritis, in which the disease was attended with hysteria, 
the risus sardonicus, and a train of symptoms bordering on mania; 
the pain on pressure was intense. He not only complained of 
a sense of burning, but he said his feelings were those of fire. 
The patient under this anxiety frequently tears off his clothes; 
his limbs are violently contracted; he changes from place to place, 
and shows an unconquerable restlessness: upon swallowing drink 
he is for a moment soothed, but the burning soon returns, and 
feels as if coals of fire were laid upon the belly. 

Under these spasmodic affections of the stomach, he vomits; 
the drink he has just swallowed is thrown out with great vio- 
lence, and is sensibly hot to the hand as it is ejected. His coun- 
tenance is pale, livid, distressed, and exhibits very much of the 
ghastly, spasmodic contraction of the muscles, that we oftentimes 
see in accute mania. When the vomiting continues, the lower 
portion of the intestinal canal is involved in the irritation, and if 
not relieved, an inverted action takes place, followed by the 
vomiting of the contents of the lower intestines. The offensive- 
ness of the discharge, as well as its peculiar appearance, announces 
it to be of a stercoraceous sort. In some instances, the inflamma- 
tion of the stomach ends in black vomiting, particularly of the 
flaky sort; i. e. portions of the vill5us coat appear to be thrown 
off; while in other instances, the matter discharged is of a coffee- 
ground appearance, or resembles a dirty brown water. These 
symptoms are not only the attendants upon that form of gastri- 
tis that is symptomatic of yellow fever, or other contagious 
fevers, but they frequently, too, follow inflammation that may 
have begun in the oesophagus, or in the cardiac, or the pyloric 
orifices of the stomach. These are fatal symptoms, and are soon 
succeeded by the cessation of all pain — a feeble pulse, cold sweats, 
cold extremities, convulsions and death. 

The appearances, upon inspecting the body after death, are 
nearly similar to those after fatal peritonitis; viz. the vessels of 
the viscera are all loaded with blood, denoting high inflammation. 
The effusion of serum and pus, flakes of lymph or of gelatinous 
exudations, adhesions of the viscera, gangrene and sphacelus of 
the part most affected. In some few cases, this disease, as well 
as peritonitis, comes on in so mild a manner, and proceeds through 



612 LECTURE LII. 

its whole course with so few of the symptoms that have been 
enumerated, and those, too, so moderate, that the practitioner, 
unless aware of the fact, will be deceived, and equally misled in 
his treatment. 

" I have seen it," says Bedingfield, " destroy life without a 
single circumstance occurring by which its existence could be 
known, or even suspected, till within a few hours of dissolution." 
(p. 182.) So of peritonitis. * I have seen," says he, "cases of 
long continued peritonitis, in which the symptoms were at first 
so mild that till within a few hours of dissolution no apprehension 
of danger was excited by them." (p. 185.) 

DIAGNOSIS. 

Inflammation of the cardiac or pyloric orifices, is slow in its 
approach. There is less active inflammation. Colic — wants the 
peculiar hard pulse. In it there is less fever; the tongue is foul; 
not the white fur. There are symptoms of jaundice; the pain 
on pressure is relieved, in gastritis increased. In gastritis the pain 
is at the praecordia, but in entiritis the pain is near and around the 
navel. In peritonitis the pain is more superficial; and in many 
cases not accompanied by sickness of stomach, or any other dis- 
turbance of the intestinal canal. In hepatitis the skin is generally 
yellow; and there is pain in the right hypochondrium and shoul- 
der. In phrenitis the state of the iris denotes the condition of 
the brain. Examine if it contracts upon the application of light, 
or if preternaturally contracted in the ordinary quantity of light. 
In that case, it shows that the irritation of the brain is probably 
symptomatic, and that effusion or congestion has not taken place, 
as after idiopathic phrenitis; which passive state of the iris gene- 
rally denotes a fatal termination. This, too, is the test of con- 
gestion; or after taking spirituous liquors, if the brain be so 
oppressed as to show the passive state of the iris, the case is usu- 
ally hopeless. If it contracts by light the patient will probably 
recover. (See Bedingfield, p. 187.) 

EXCITING CAUSES. 

Cold. — The free use of cold water, when the body is heated. 
Of this I have seen many instances; i. e. when previously excited 



GASTRITIS. 613 

by spirituous liquors, this effect is more likely to be produced; 
but this additional source of excitement is not necessary. The 
body operated upon by heat, or excited by exercise, and spirituous 
liquors, previous to the use of cold water, is sufficient to prepare 
the body for the action of cold as the exciting cause. 

The metallic poisons are another common source of gastritis — 
such as copper, arsenic, lead, antimony, &c. It arises, too, from 
vegetable poisons, such as opium, and the use of various poison- 
ous plants. It will be produced by small pox, measles, scarlatina, 
typhus fever, yellow fever, &c. 

Yellow fever, as you have seen, in a peculiar manner vents 
itself upon the stomach, as the very seat and throne of the dis- 
ease. In like manner, aphthae in children, and indeed in adults ? 
spread through the stomach and intestines, producing inflamma- 
tion as they proceed, showing it even at the anus in white ulcera- 
tions. So with gout ; inflammation of the stomach is not unfre- 
quently the effect of the pain, spasm, and other attendants upon 
the indigestion so intimately connected with that disease; while 
the accustomed fulness of habit in gout soon inundates and in- 
flames the seat of irritation, whether it be the brain or stomach : 
they therefore die of phrenitis or gastritis, occasioned by the ex- 
citement of the system falling upon a very excitable organ, but 
not from any peculiar virus, which most persons associate with 
gout. And let me tell you, that while certain professors profess to 
reprobate the humoral pathology as taught in this college, they 
teach this very doctrine, as it regards this subject, to an inordinate 
extent, which I should deem altogther unwarrantable and absurd. 
The late distinguished Mr. D., of Philadelphia, died of an apo- 
plexy; forsooth, it was denominated gout in the brain. Another 
person sinks under gastritis; this too is gout in the stomach. An- 
other man is ill of the pains of rheumatism ; it is a flying gout. 
These extravagant remains of the humoral pathology I trust will 
find no place in this school, however warmly urged, or pertina- 
ciously retained elsewhere. So far then the dyspeptic stomach 
and full habit of gout may beget gastritis. It may arise from a 
blow on the stomach; a wound by cutting instruments, needles 
swallowed, or injury by a ball. It may arise from the irritations 
of indigestible substances or of overgorging, as in the case of the 
man who fell a victim to his folly in swallowing a great number 
of knives. It may be produced by the excessive use of spirituous 



614 LECTURE LII. 

liquors. In this manner the cases of inflammation and disease of 
the stomach, originally from an affection of the orifices of that 
organ, are induced very frequently. In like manner such is the 
effect of excitement. I have no doubt that the mental anxiety and 
vexation which Napoleon experienced upon his fatal rock, laid 
the foundation of the diseased state of the stomach that terminated 
the existence of that distinguished and most extraordinary man. 

TREATMENT. 

Venesection, general and local, by leeches, large and repeated. 
As I before said, let not the small pulse or the pale visage deter 
you from the free use of the lancet, which alone can preserve 
your patient. Use caution in typhus, and in the exhausted de- 
bauchee; blisters must be applied early; clear the bowels by ene- 
mata; these may be thrown up frequently; but before the inflam- 
matory symptoms have been subdued, and the irritability of the 
stomach allayed, neither food nor medicine can be retained; 
indeed they only serve to aggravate the disease ; cathartics will 
not be retained. Use laxatives, such as calcined magnesia, and 
castor oil ; administer the warm bath, but no ice or cold applica- 
tions to the belly, as urged by Thomas. All your remedies should 
be simultaneously applied, for if the patient be not relieved in 
twenty fours, at farthest, the disease will probably prove fatal. 
Apply fomentations to the extremities ; use the saline mixture, 
soda water, lime water and milk, milk and water — especially if 
proceeding from metallic poisons. Yeast is another anti-emetic; 
and sometimes let the stomach rest, by giving nothing. Emetics 
are recommended by some for the removal of vegetable poisons ; 
but here great caution is necessary. Opiates too are of dangerous 
tendency, before evacuations have been obtained. Then you may 
use Dover's powders, or opium, with spiritus mind, or with ipe- 
cacuanha, to act on the surface. The diet should be milk and 
water, rice water, barley water, gum arabic in water, flax seed tea, 
soda water, with additional soda, lime water and milk. The regi- 
men must be as in the treatment of other diseases of excessive 
excitement. 



615 



LECTURE LIII 



HEPATITIS. 



Hepatitis, or inflammation of the liver, is characterized by 
fever; tension and pain in the right hypochondrium, oftentimes 
as pungent as that of pleurisy, oftener obtuse ; pain shooting to 
the clavicle and top of the shoulders; the patient lies with diffi- 
culty on the left side, attended with difficult respiration, dry 
cough, vomiting, hiccup. Sauvages and Sagar add to their defi- 
nitions or characteristic symptoms, the yellowish colour of the 
skin, yellow urine, and yellowish serum in the blood drawn. 
These last are equivocal symptoms, depending on the part of the 
liver the seat of the disease ; they are the evidences of one form 
of the disease, but not of another; as they are therefore not con- 
stant or essential symptoms, they are accordingly omitted by Lin- 
naeus and Vogel. The pain and inflammation, when seated in 
the membranous coverings of the liver, say from a blow, or what- 
ever cause, will not necessarily derange the functions of the liver 
so as to effect the secretions, or to prevent the flow of bile into 
the intestines; therefore, this discharge, not being interrupted, it 
will not show itself in the complexion, in the urine, or in the 
blood drawn; consequently they are equivocal symptoms, i. e. of 
membranous hepatitis, though they are among the symptoms of 
that form of the disease which extends to, or is orignally in 
the parenchymatous portion of that organ. Inflammation of the 
liver, like pneumonia, I divide into two species. 1st That spe- 
cies which is seated in the membranes of that gland: and 2d. that 
which occupies the parenchyma, or cellular portion of it. Dr. 
Cullen has, in my opinion, made a very bad division of it into 
acute and chronic inflammation of the liver. The latest writers, 



616 LECTURE LIU, 

too, Drs. Thomas and Pemberton, among the rest, have followed 
him, without the least question of the correctness of that division. 
The term chronic inflammation, in my opinion is a bad term to 
apply to a primary inflammation, when seated in an organ of so 
much importance to the animal economy. It paralyzes the exer- 
tions of the physician, for he naturally thinks that as the disease 
is chronic, he too may be chronic in his remedies, and take his 
time for the cure of it. On the contrary, you have as much acute 
inflammation to contend with in Dr. Cullen's chronic species as 
you have in his acute form of hepatitis; nay, you have occasion 
for all your acuteness in detecting this form of the disease; for 
like the inflammation constituting the first stage of phthisis pul- 
monalis, (and indeed the same may be said of inflammation in the 
parenchyma of the brain, and the uterus,) it is extremely insi- 
dious in its approach, and such too is the mischief it creates, by 
the time the ordinary observer detects its existence, that you have 
reason to be very active in the use of all the means in your power 
for its removal, for frequently when you discern the disease, 
death stares you in the face. We shall therefore prefer the dis- 
tinction which I have proposed, into membranous and parenchy- 
matous inflammation of the liver, to Dr. Cullen's acute or chronic, 
which last should be blotted out altogether from books of prac- 
tice; for even when the parenchyma of the liver has become ob- 
structed from other causes, and inflammation supervenes, such 
inflammation is still acute, wherever it may present itself. Its 
symptoms, I grant, will be less severe and less easily detected, 
but they are so, as before remarked, because the inflammation is 
seated in a less sensible part of the body. Hence it is, that it is so 
frequently overlooked, and, as Dr. Cullen says, only ascertained 
after death, and then by the abscesses that are at that time found. 
But Dr. Cullen has not been as much conversant with hepatitis as 
the practitioners of the East and West Indies, and of this climate. 
But at this we are not surprised, when we find physiologists like 
Baron Haller, (El. Phys., vol. vi.,) denying that the internal 
substance of the liver possesses any degree of sensibility. Let us 
not, however, go to the other extreme, and join with a writer in 
the Memoirs of the Academy of Sciences, 1766, Mons. Farrain, 
who affirms that this latent inflammation may be certainly known 
by the pain felt upon examining the liver, near the xiphoid carti- 
lage, and that it is the source of all the pains generally attributed 
to the stomach. 



HEPATITIS. 617 

We shall now proceed, agreeably to our division, to notice 
the characters, progress, causes, and treatment of the first 
species, that which is seated in the peritoneal coverings, or 
membranes of the liver. It announces itself as most of the 
phlegmasia^, by chill, succeeded by the general symptoms of pure 
synochal fever, and of local inflammation; the part affected imme- 
diately, or very early in the disease, is attended with an acute 
pain in the right side; and such is the connexion by nerves be- 
tween the liver and stomach, that this pain also frequently affects 
the praecordia, and oftentimes extends to the clavicle, to the joint 
of the shoulder, (the physician, if not careful, will consider this 
pain as a rheumatic affection of the shoulder,) and to the scapula. 
These last symptoms arise from the connexion which exists be- 
tween the phrenic nerves and the second and third pairs of the 
cervical nerves. Be careful, however, to distinguish it from 
similar pains which are occasioned by an adhesion formed be- 
tween the lungs and diaphragm. Mr. White, a writer upon the 
virtues of antimony, has the following judicious observation upon 
this subject: " When a patient complains of a constant dull pain 
in the right shoulder, it is looked upon as a pretty certain sign of 
a diseased liver; but this," says Dr. White, "requires restriction, 
as that pain may be felt, and yet the liver be free from disease • 
and the liver may be diseased without causing such pain. If an 
inflammation seizes the liver on its right side, but not extending 
so far as the coronary ligament, it will net produce a pain in the 
shoulder; but if that ligament is affected, that pain is immediately 
produced. The reason is, the coronary ligament is connected to 
the diaphragm, upon which runs the phrenic nerve, which com- 
ing out from the third or fourth vertebrae of the neck, sends a 
branch which is spent upon the muscles of the shoulder. As this 
pain is felt, for the same reason, when the lungs adhere to the 
diaphragm, it is no pathoguomonic symptom of a diseased liver." 
(White on Antimony, 12mo. p. 157.) But it is remarked, and 
very justly, by Dr. MacBride, (p. 446.) that the pain and other 
symptoms of this affection of the liver, exhibit some variety, ac- 
cording as the inflammation is seated on the convex or concave 
side of that viscus That, when seated on the convex side of the 
liver, the pain is increased by the movement of the diaphragm, 
extending along the mediastinum, throat and clavicle. That there 
is also a great increase of pain on lying on the left side, while there 
53 



618 LECTURE LIII. 

is a very sensible soreness to the touch on the right side. But, 
again, that when the inflammation is seated in the concave side, 
that the patient can turn with more ease, that it is not so severe, 
that he is not so much affected by the movements of the dia- 
phragm, and that it is usually attended with great sickness of sto- 
mach and vomiting, and a sallow appearance of the skin, owing to 
the parts of the liver more immediately concerned in the secre- 
tion of bile, occupying the under or concave portion of that organ. 
I have a patient now (1824-5,) ill of hepatitis. This disease is 
seated in the anterior and convex portion, so large as to press on 
the stomach, to prevent the diaphragm from descending, to pro- 
duce cough; the patient is obliged to lie chiefly on the back ; yet 
no sickness of stomach, except by spasm; no derangement of the 
biliary organs, no yellowish skin or eyes, no yellow fur on the 
tongue; still it will go on, and probably prove fatal. The pulse 
in this disease, as when inflammation is seated in other dense 
membranes, is corded, hard, and frequent. The tongue too is dry, 
and covered with the white fur, and attended with much thirst ; 
the skin is dry and hot; the excretions generally diminished; the 
biliary among the rest. But when vomiting is produced, a free 
discharge of bile shows itself, as we remarked was the case in 
peritonitis and gastritis, i. e. that the circulation through the liver 
is rapid, and when the excretories are unlocked by nausea and 
vomiting, that, in that case, they pour out an inordinate quantity 
of bile. The countenance is not generally yellow in membranous 
inflammation of the liver; the urine too, at first, is pale, but when 
the vessels are highly injected, the urine is voided of a very high 
colour, partly partaking of the fluid from whence it has been so 
rapidly separated. A cough, especially after the first forty-eight 
hours, is also a very constant symptom of hepatitis. 

DIAGNOSIS. 

This disease may readily be mistaken by the hasty observer 
for a common pleurisy, or an inflammation of the diaphragm: and 
as the stomach is much affected by it when seated in the concave 
side of the liver, it may also be confounded with bilious colic, 
when arising from biliary concretions. In pneumonia there is 
more cough, and earlier than in hepatitis; there is more difficulty 
of respiration; no pain of the shoulder, White's exception ; not the 



HEPATITIS. 619 

irritation of the stomach. Hepatitis, too, wants the peculiarities of 
diaphragmitis, and is easily distinguished from bilious colic. Hepa- 
titis has fever, colic none, unless from the long continuance. In 
hepatitis the pain is constant, with a sense of burning in the part; 
in colic it returns periodically, and is more severe while it conti- 
nues. The patient in the one case is doubled up with the torture he 
endures; in the other, his pain is constant, and especially increased 
by the touch; in colic the pressure of the hand gives relief. Hepa- 
titis terminates by resolution, when plentiful evacuations are either 
effected spontaneously or by art; as by early hemorrhage or 
diarrhoea coming on spontaneously, the disease has been suddenly 
and unexpectedly removed. In like manner, by the artificial 
means of depletion to be pointed out, this termination may be ex- 
pected when administered early. When the patient is thus re- 
lieved, the pain is greatly diminished, and the secretions are all 
restored. Be careful, however, how you pronounce the patient 
relieved from danger, by the mere cessation of pain; for such 
sudden release frequently announces fatal consequences. How 
are we then, to distinguish this symptom when favourable, from 
the same, when it proves the forerunner of dissolution? When 
favourable it is accompanied with a return of the perspiration and 
other excretions attended with a natural temperature of body. 
When unfavourable, the patient sweats freely, but they are cold, 
clammy sweats, and attended with a livid countenance, and with 
cold extremities. But hepatitis left to itself, also frequently pro- 
ceeds, secondly, to suppuration, known by chills and hectic fever, 
and an elastic feel of the part. Cases also are recorded where it has 
found a passage through the colon. In other instances it has been 
discharged into the cavity of the abdomen, when it for the most 
part proves fatal; or it occasionally has been known to end, thirdly, 
in gangrene or sphacelus; and it has ended in dropsy of the belly; 
that is, the inflammation has terminated by serous effusion analo- 
gous to hydrothorax, the effect of pneumonic inflammation, espe- 
cially if neglected or inactively treated. When it terminates in 
suppuration, if the inflammation be on the convex side of the 
liver, it either discharges itself externally, rinding its way through 
the muscles and integuments covering the abdomen, which is 
the most common event; or it involves the diaphragm, pleura, and 
lungs, and is at length discharged by expectoration. But this is 
comparatively of rare occurrence, and is for the most part, fatal. 



620 LECTURE LIII. 

Not so in the Bridewell case, nor in the case in the hospital; nor 
in the case of Dr. Bard's patient, of which I have spoken. 

Again, if seated in the concave side, it has been known to com- 
municate with the biliary vessels, and the matter formed, dis- 
charges itself through the intestines. But in cases where it 
proves fatal, upon examining the body after death, extensive ad- 
hesions are found to have taken place, not only of the liver, to 
the adjacent organs, but of most of the abdominal viscera to each 
other, with large purulent or serous effusions, as after enteritis. 
The liver, too, undergoes great change; its whole substance being 
rendered more hard and compact, throughout its whole texture 
assuming the scirrhus condition; at the same time that it under- 
goes considerable enlargement, extending to the left hypochon- 
drium as well as occupying the right: for the liver, as we have seen 
in the fcetus, when supplied with an inordinate quantity of blood, 
readily admits of great distention. The weight of the liver in 
health is about three and a half pounds; by distention it frequently 
increases to eighteen or twenty-four pounds. Such is the current 
permitted to take place to the diseased organ before the malady 
is discerned or active measures pursued. In the case related of 
diseased liver, by Bartholine, that organ was so much enlarged 
that it weighed forty pounds ! 

The causes are similar to those of the phlegmasia^ in general. 
The predisposing are, a plethoric habit of body, the sanguine tem- 
perament, intemperance, and especially a preceding attack, or 
previous injury affecting that part. The exciting causes for the 
most part, are local violence, as from a wound or blow, and cold; 
and in some cases it is symptomatic; that is, derived from the in- 
flammation of the adjacent viscera, being extended to the liver by 
continuity of membrane. Even pleurisy has been known in 
some instances to have involved the liver, and much more so will 
inflammation of the peritoneal covering of the abdominal viscera 
extend itself to that particular viscus; but in common with other 
abdominal inflammations, it has also been induced by the suppres- 
sion of eruptive diseases, as erysipelas and others. 

Treatment of this disease as in peritonitis, or by repeated and 
liberal bloodletting. In such case the bleeding must be large and 
repeated to the third, fourth, or fifth time, allowing due intervals 
in which to judge of its effects, and to ascertain how far the 
strength of the patient will endure it. Celsus gives us a good 



HEPATITIS. 621 

rule upon bloodletting: " Interest enim non que setas sit neque 
quid in corpore intus geratur, sed que vires sint?" (Celsus, lib. 
2. cap. 10.) Pemberton directs it to be taken too, from a large 
orifice, in order to produce all the advantage of relaxation. This 
practice is questionable — though recommended in all the books. 
But in the case of the other means of depletion, be especially 
careful to employ those which are peculiarly useful in restoring 
the secretions of the liver, as well as the functions of the system; 
thereby you will diminish the fulness of that organ more than 
by any other means; analogous to the relief afforded by dis- 
charges from other glands and mucous membranes when they are 
the seat of inflammation, as the tonsils, &c. With this view, the 
mercurial purges, jalap and calomel, aa. gr. x. and the saline, are 
peculiarly beneficial. Blisters, too, should also be early applied 
in this complaint, and as near as possible to the parts affected. If 
the patient be not relieved in a few hours repeat the lancet; and 
this to be succeeded by large doses of calomel* and antimony, or 
the solution of antimony in nauseating doses, aiding its operation 
upon the surface by occasional fomentations, bathing the feet in 
warm water, and the frequent use of the thin tepid drinks which 
have been so frequently recommended in inflammatory diseases. 

The same abstinence in diet, and attention in all respects, to 
the regimen of your patient, are also called for in this as in other 
acute inflammatory diseases. 

The next species of inflammation of the liver, is that which is 
seated in the parenchymatous or cellular portion of that organ; 
improperly called by Drs. Cullen, Thomas, Pemberton, and others, 
chronic inflammation. Dr. Cullen states, that it has no character- 
istic symptoms, by which it may be known. As I remarked 
yesterday, Dr. Cullen has not had an opportunity of seeing many 
instances of hepatitis, except that seated in the membranes invest- 
ing the liver, or he would have given you a different view of this 
subject. In the East and West Indies, in the tropics generally, 
and in our own country, this disease is frequently met with in all 
the various forms which that disease assumes, whether it affects 
the external coats of that viscus, or its interior structure. This 
species of hepatitis, as I remarked, like peripneumonia or phthi- 

* Calomel alone, and in small doses, is highly objectionable. It adds to the in- 
flammatory action, as I have said upon other occasions. 
53* 



622 LECTURE LIII. 

sis, makes its attack and its advances in a very insidious manner. 
Instead of the sharp, pungent pain of membranous inflammation, 
the patient only complains of a dull, heavy, solemn pain in the 
side, a sense of weight in the right hypochondrium, with the 
feeling of unusual fulness on the same side, and occasionally a 
shooting pain reaching to the clavicle, shoulder joint, or the sca- 
pula. In some instances, this pain is considered as merely a 
rheumatic affection of those parts, and the real seat of the disease 
is overlooked. But the patient does not alone complain of these 
local symptoms; he is himself sensible of a degree of feverish- 
ness; but compared with that of the first species, it may be deno- 
minated a febricula; yet there is manifestly a quickened circula- 
tion; the pulse is frequent, but comparatively soft and full; not 
the tense, corded pulse of membranous inflammation. I can 
speak very feelingly on this subject, having experienced this dis- 
ease some years since; but which I have since prevented by the 
use of the lancet, two or three .times a year. The patient, too, 
is sensible of increased heat, and especially burning of the hands 
and feet, attended with some thirst, and clamminess of mouth. 
He has a great disinclination for motion or exertion of any sort, 
whether mental or bodily. His functions, to a certain degree, 
are all more or less disturbed. His days are passed in dulness, 
and his nights are restless. He is especially impatient under the 
stimulus arising from the heat of his bed. He can only lie on 
his right side, for on the left the great weight of his overloaded 
and irritated liver renders him at least very uncomfortable, if it 
does not produce acute or severe pain. His nervous system is 
also much affected. His sleep is imperfect and unrefreshing. He 
dreams, he starts, and is much disturbed. And such, too is the 
interruption of the pulmonary circulation by the pressure of the 
liver on the diaphragm, that incubus, in all its distressing forms, 
is a frequent attendant on this disease. The blood crowds the 
part affected: and such, too, is the determination to the part 
affected, that his extremities are frequently cold, while his vessels 
are loaded, and his circulation sensibly increased. His respira- 
tion, too, is much oppressed; especially upon exercise, or when 
ascending a staircase; for there is a greater quantity of blood in 
all the larger vessels of the body, and circulating through the 
lungs; besides the effect of the enlarged liver, pressing up the 
diaphragm, and diminishing the capacity of the chest, and the 



HEPATITIS. 623 

increase of the circulation. And sometimes the pressure upon 
the chest so affects the pulmonary circulation, that it produces all 
the symptoms of angina pectoris. Sometimes the lungs are so 
much oppressed that the blood does not readily return from the 
head; giddiness; double vision; a bloated state of the feet; numb- 
ness of the extremity result. His tongue, especially in the morn- 
ing, after a feverish night, is furred and foul; covered, not with the 
white fur attendant upon membranous inflammation, but a yellow 
sordes, as if stained with bile. His teeth are also covered with 
a similar matter. His skin frequently assumes a dirty, dusky 
brown colour. The adnata^ of the eyes are of a yellowish hue. 
His urine becomes muddy. His bowels are costive. His stools 
become either clay-coloured, showing no bile in them, as in the 
stools of jaundice, or they are of a dark brown colour; i. e. co- 
loured with bile that has been long secreted, and long pent up in 
the gall-bladder, or gorging the biliary vessels. All these sj^mp- 
toms are referrable to the derangement produced in that part of 
the liver which is devoted to the secretion of the bile; those 
vessels being obstructed and constricted by the inflammation they 
undergo. These circumstances enable us satisfactorily to explain 
the fact recorded by Dr. Girdlestone, that chronic dysentery is 
frequently found connected with a diseased state of the liver, and 
that abscesses are oftentimes met with in that organ under similar 
circumstances. It was dysentery, therefore, symptomatic of a 
diseased liver, but not originally a dysentery that could have 
produced inflammation of the liver. 

Among the other symptoms of this species of hepatitis are 
great irritation of the stomach, showing itself in great nausea, 
and sometimes vomiting; sometimes from nervous connexion, at 
other times by mechanical pressure of the liver upon the stomach. 
In some cases bile is thrown up, but this rarely occurs, and when 
it does, it is not bile of its natural yellow colour, as when newly 
secreted, but of a brown dark appearance, very much altered 
from its natural qualities and character. This form of the disease, 
too, not unfrequently attacks the bilious habit, that is, one who 
perhaps has been accustomed to large bilious secretions; in other 
words, of a full habit of body, and a debilitated state of the diges- 
tive organs, the liver and its excretions being affected in propor- 
tion to such fulness and irritation, the attendant on a debilitated 
state of those organs. A stricture now existing on the secretory 



624 LECTURE LIII. 

vessels of the liver the bile is re-absorbed, and returned to the 
blood, and thence appears in all the other secretions, while the 
gall-bladder rarely empties itself except by a very active emetic; 
when frequently a viscid snuff coloured bile is forced out of it, or 
perhaps gallstones are let loose in the relaxed state of the vessels 
which attends upon vomiting. In this state of the liver the abdo- 
men is very considerably enlarged; and the patient lying upon 
his back, with the abdomen muscles relaxed, and his thighs bent 
on his body, the liver is frequently found not only very hard, 
but so much enlarged as to extend even to the left side of the 
belly, though this we know is not its extent in a state of health. 
But when thus filled and distended by disease, it occupies the left 
as well as the right hypochondrium; and its margin may be dis- 
tinctly traced. But it is also proper to examine in an erect or sitting 
posture, for frequently lying on the back the liver retires within 
the margin of the ribs, and is not so easily felt; but in an erect 
posture, the liver descending about two inches below the edge of 
the ribs, its disease is for the most part more easily ascertained, 
especially upon inclining the spine forwards and towards the left 
side, and the part being examined during an inspiration, but when 
examining the patient on his back, examine during respiration. 
Moliere's joke about the heart is almost realized with regard to 
the liver; that is, it appears to have changed sides. Be cautious, 
however, in your decisions, and remember that it is not unfre- 
quently the case that the spleen, which occupies the left side, is 
also enlarged at the same time with the liver, for the same causes 
which operate in producing the one effect not unfrequently pro- 
duce the other. Obstruction of the spleen will produce an inordi- 
nate flow of the blood into the liver, being both supplied by 
branches of the coeliac, the circulation in the one diminished the 
other is necessarily increased. So a gorged state of the coronaries 
of the stomach by overfeeding, will load the liver; another reason 
why gluttons have overgrown livers. You can scarcely, however, 
make the mistake committed by one of my fellow practitioners, 
who pronounced a lady of my acquaintance having a calculous 
affection of the left kidney, to be ill of a disease of the liver! That 
a mistake as it regards the right kidney, should be made, is not 
surprising, for it has frequently happened, (see Portal,) that the 
enlarged liver extends downwards and backwards so far as to de- 
press the right kidney, (see Repertory, sixth volume, p. 49,) and 



HEPATITIS. 625 

even to occasion gravel, (p. 65,) and great pain in the right lum- 
bar region; or perhaps the obstruction of both viscera may have 
arisen from the same state of the blood vessels. This form of 
hepatitis, like the membranous, has various terminations. In some 
instances this loaded state of the liver relieves itself by an unex- 
pected hemorrhage or diarrhoea. Portal, who has recently writ- 
ten on the diseases of the liver, I find makes a similar observa- 
tion, that hemorrhage from the liver either thrown up by vomit- 
ing, or passed off by the bowels, is in general salutary, though in 
some cases it is followed by fatal exhaustion. (See Eclectic Re- 
pertory, Vol. vi. p. 53.) In like manner resolution is also effected 
by similar or analogous evacuations procured by art. A second 
termination of hepatitis, is by abscess, which in some instances 
has been so large and extensive as almost to excavate the liver, 
leaving the membranes a mere bag. Yet it is strange to tell, that 
Dr. Cullen could have committed the error of supposing suppu- 
ration ever to occur in this or any other organ without preceding 
inflammation and fever! Thirdly, in some instances it ends in 
large tubera, tubercles, or small abscesses, and the matter being ab- 
sorbed, these are left in a scirrhus condition. But in other cases, 
the whole liver becomes so much consolidated and obstructed as 
to constitute a perfectly scirrhus state of the greater part of that 
viscus, analogous to the scirrhus of the breasts and testes, after 
inflammation. I pass over the nice distinctions made by Portal, 
such as his lymphatic obstruction, his albuminous, his gelatinous, 
mucous, and serous ! There is more affectation in this attempt 
to delineate the varieties of this obstruction than utility, or in- 
deed than truth; for it is impossible to distinguish them in life, 
and if we could do so it is not calculated to answer any important 
or useful purpose, at least that I can perceive. Subtle distinc- 
tions indeed, only serve to darken, not to enlighten, the subjects 
of our inquiries. When a physician like Portal, can recom- 
mend oil of worms, oil of puppies, oil of bricks, and pigeon's 
dung as a plaster for some of these affections, what can you think 
of him or of his opinions and his distinctions? These obstruc- 
tions constitute the chronic disease of the liver, that is, after in- 
flammation has subsided. Indeed it is very possible that acute in- 
flammation may be even revived in this very chronic or scirrhus 
condition of the liver, in the same manner as we see inflamma- 
tion and ulcer to take place in the breasts and testicles, or uterus, 



026 LECTURE XIII. 

constituting supposed cancer. A fifth termination of the inflamed 
or enlarged liver is by venting a serous effusion into the abdo- 
men, constituting a dropsy of the abdomenical cavity or ascites. 
Case of Mr. N G , in whom the original disease was in- 
duced by a full habit of body, full living, and cold. Active mea- 
sures were not employed; the physician, a Frenchman, kept his 
lancet in his pocket when it should have been on his patient's 
arm. Nature, in this state of the vessels, unloaded herself by 
serous effusion, but she destroyed the patient But let us ask how 
does such enlargement of the liver produce ascites? First, by an 
excitement produced in every vessel circulating on the abdomi- 
nal viscera and cavity; the great determination to the abdominal 
viscera in general. Secondly, by the enlarged viscus pressing 
upon the adjacent vessels and impeding the free return of blood 
in the veins; this impediment will necessarily create a diseased 
exhalation. Thirdly, the indurated condition of the liver itself, 
obstructing the return by the venae portarum, must crowd the 
other vessels, and increased exhalation must necessarily be the 
consequence as well as the effect of long continued excitement.* 
Fourthly, by a diminished power in the absorbents. Such gene- 
rally are the chronic consequences of preceding acute inflamma- 
tion of the liver, when thus seated in the parenchyma or cellular 
structure of that organ. 

CAUSES OF THE SECOND SPECIES OF HEPATITIS. 

One of the most prevalent of the predisposing causes is general 
plethora. Remember that the blood of the abdominal viscera in 
its return to the heart, for the most part passes through this organ, 

* Another consequence of this pressure on the returning- vessels is hemorrhoids; 
hence the piles are so frequently noticed by practical writers as the attendant on 
diseased liver. In like manner the enlarged liver pressing upon the returning 
cava is said also to produce a varicose enlargement of the vessels of the lower 
extremities and anasarca. Another effect of this loaded and obstructed state of 
the liver is to produce an intermittent pulse, which both Morgagni, Epist. 36, art. 
24, and Pemberton, account for by supposing that the blood conveyed by the 
hepatic artery not finding a ready passage through the hardened viscus, is thrown 
back upon the heart, and thus interrupts the regular action of that organ. So in 
like manner Pemberton accounts for the fluttering and pulsation at the pit of the 
stomach from the interruption of the vena portarum in consequence of the obstruc- 
tion of the liver. In that case the vena portarum is filled and distended, and com- 
municates the sense of undulation, considered by some to be aneurism. 



HEPATITIS. 627 

by the vena portarum, independent of the supply of that viscus, 
by means of the hepatic artery. You also well know, that this 
organ is capable of great distension, as we see illustrated by its 
enlargement when the blood conveyed to it in the foetal state, by 
means of the umbilical vein, is distributed in that viscus which 
becomes nearly as much enlarged in the left as it is in the right 
side. And when this supply is cut off, and the biliary vessels 
are emptied of their meconium, with which they are loaded until 
compression is produced upon the body in labour, or by the res- 
piration after birth, the liver then ceases to be so extended, and 
confines itself afterwards to the right hypochondrium, unless 
by some inordinate supply, the effect of disease or intemperance, 
it may again become enlarged in the progress of life. In this 
plethoric state of the body, the liver and the spleen, as well as 
the uterus, the breasts, and the brain, may be considered as so 
many cisterns to the blood-vessels, receiving the surplus blood of 
the system; and by their fulness manifesting such accumulation; 
and of course, in a condition to be readily excited to inflamma- 
tion upon the application of an exciting cause. Accordingly, it 
happens that hepatitis of this species rarely occurs but in pletho- 
ric habits. The greater part of the patients I have seen affected 
with such hepatic obstruction, were persons of a full habit of 
body, and in habits of full feeding and hard drinking — living, 
too, a sedentary life. So, in like manner, the relative plethora 
which takes place after the natural cessation of the menses is fre- 
quently productive of this engorged state of the liver, and liability 
to inflammation. 

Another predisposing cause is a previous attack, rendering that 
the weak and irritable part. 

A third is violence done the part, by external injury, as the 
effect of a fall — as in my own case. 

Under such circumstances of predisposition, the liver becomes 
easily affected with inflammation upon the application of an ex- 
citing cause; and that, too, frequently a slight one. 

The exciting causes of this species of hepatitis are, for the 
most part — 

1st. The heat of climate operating upon the full habit, unaccus- 
tomed to such high temperature. Heat, operating upon a full 
habit of body, as with persons recently arrived from a northern 
climate, necessarily increases the force of the circulation. This 



628 LECTURE LIII. 

impetus, too, will exhibit itself upon such parts of the body as 
are more distensile and yielding in their structure. The liver will 
partake most largely in this respect, not only from the impetus of 
its circulation, but from its great supplies by the venous system of 
the belly, and the vena portarum. Hence the extensive preva- 
lence of this disease in the East and West Indies ; in the tropics, 
and in our variable climate — especially in Europeans, newly 
arrived. 

2d. Intemperance in eating and in drinking ; and especially 
the excessive use of vinous, spirituous, and fermented liquors. It 
is accordingly remarked, that diseases of the liver occur more 
frequently, and are more rapid in their progress at the pay-time 
of the troops, both in the East and West Indies, than at any other 
time. (See Simond's Journal, Vol. i. 397.) The too free use of 
spices, and other condiments, calculated to excite the appetite, 
already impaired by excess. These, too, usually co-operate with 
the heat of climate to produce diseases, especially of the liver; 
and the digestive organs of the stranger, newly arrived, and who 
insensibly falls into these habits, and the dissipation so prevalent 
in hot climates. Thus initiated, he now takes his punch, his 
sherbet, indulges in the immoderate use of acids, cayenne pepper, 
and other excesses of the table. Hence it is, that in those hot 
regions free livers very soon make full livers. It is upon the 
same principle, that epicures stuff their geese for the express 
purpose of enlarging the liver, which is esteemed by them one 
of the greatest delicacies; (the celebrated patte des fois grasses 
is thus prepared.) They make him drink incessantly, and feed- 
ing him at the same time, as much as he can swallow, and 
enlargement of the liver is the result. In like manner, the 
human goose, under the fire of the tropics, excited by hard 
drinking, and gorged by free feeding, begets a similar enlarge- 
ment of the liver; for under this excitement, the digestive or- 
gans, and the whole system, are all soon affected, either di- 
rectly with inflammatory diseases, or prepared to be so by the 
debility they produce, rendering them liable to such inflammatory 
action upon the check of perspiration by the cold of the night 
air, one of the most frequent exciting causes of inflammatory 
disease, especially in the hot latitudes. But spirituous liquors 
do more than all the rest in producing this disease. The fable of 
the vulture feeding thirty thousand years on the liver of Prome- 



HEPATITIS. 629 

theus, as a punishment for stealing fire from heaven, is certainly 
a happy and an instructive illustration of the pernicious, as well 
as the chronic effects of ardent spirits upon that organ of the 
body. The figure is well sustained when it states that the liver, 
though constantly devoured, was not diminished, denoting the 
chronic disease, and enlargement, which are the consequences of 
this worst of all fires, that act upon the human system — rum drink- 
ing. Such debility, too, is also induced by the habitual use of 
medicines, to unload their already gorged digestive organs; and 
especially the indiscriminate use of mercury. For, as I have be- 
fore remarked, in the West Indies, every case of dyspepsia is 
considered as a diseased liver! But this debility is not confined 
to the digestive organs. The venous system soon partakes of it. 
That part of it connected with the liver and abdominal viscera 
must necessarily become affected by it. Congestion will thus 
readily take place in the vena portarum, and its branches in the 
liver. And the least obstruction taking place to the free passage 
of blood through that distensile viscus, disease rapidly ensues. 
Another circumstance perhaps has its influence. Portal remarks, 
that the veins of the liver are proportionally smaller than in other 
organs, and particularly small compared with the size of the 
hepatic artery and vena portarum. If so, we may observe at the 
same time, an inordinate proportion of blood is conveyed by these 
two vessels to the liver, the less rapid returning it by the smaller 
veins must render that viscus peculiarly prone to sanguineous 
congestion. Especially, too, when the venous system becomes 
debilitated by age, intemperance, a hot climate, and its attendant 
excesses. 

But the absorbent system no less partakes of the debility thus 
induced. Hence it is too that dropsy and a diseased liver are so 
generally associated ; not only because the exhalation is increased, 
by the causes I have before enumerated, but also that the absorb- 
ent system is less active in the performance of its duties, in car- 
rying off the effused fluids. Thus, too, it happens that fevers, 
intermitting and remitting, from their long duration in our south- 
ern states, as well as in hot climates generally, are followed by 
visceral obstructions and dropsy. But this disease is not unusual 
in this climate, as well as in the East or West Indies ; and that 
too, from the same predisposing and exciting causes. The same 
fulness of habit, the same debauchery and manner of living, pre- 
54 



630 



LECTURE LIII. 



pare the body to be acted on by cold and the other usual exciting 
causes of inflammation in this as in other countries, Indeed, what- 
ever excites and debilitates the nervous system, those organs, the 
liver, the stomach, and the spleen, are ever among the first to feel 
disaffected, and that too whether operated upon through the me- 
dium of the mind or body; especially this is the case if circum- 
stances occur to fill the system, as in pregnancy, or when suck- 
ling. Mrs. P. is always affected with this congestion of the liver 
whenever she was with child, or giving suck ; venesection, how- 
ever, takes off the plethora thus existing. In the treatment of this 
inflammatory affection of the liver, seated in the parenchyma of 
this viscus, we .should pursue the same system that has been point- 
ed out in peripneumony, or in phthisis pulmonalis, viz: venesec- 
tion, according to the age, temperament, habit of body, period of 
the disease, strength of pulse, mode of life, consistence and colour 
of the blood drawn. 2d. Attention to the excretions in general, 
but especially those of the liver itself; saline purges, sulphate of 
soda, calomel and jalap, senna and cream of tartar, Croton oil, 
elaterium, &c. But the object of these is not only to restore the 
excretions by the liver and intestinal canal, but to diminish the 
general fulness of the habit, by obtaining large discharges of the 
serous fluids of the system, and to create a revulsion from the 
part. 3d. With the same view, blisters should be applied, and 
that, too, early, over the right hypochondrium. Dressing them 
with mercurial ointment will also be proper; for if the ointment 
should not be absorbed, it will be useful, like the savin ointment, 
by keeping up a degree of soreness that would otherwise subside 
with the common dressing. 4thly : If the pain still continues, 
with the other symptoms denoting the continuance of the conges- 
tion and inflammation, next have recourse to the James' pow- 
ders, and antimonial solution, in small doses. When the active 
inflammatory symptoms are subdued, and tumor remains, a com- 
bination of calomel and James' powder will be proper, not only 
as a cathartic, but with the view to their alterative effects, or to 
the possible operation of mercury on the salivary glands. 5th. 
Then leave your patient to small doses of calomel, night and 
morning, with the express view, not only of quickening the ab- 
sorbent and circulatory vessels, but the affecting the mouth. For 
this purpose, too, combine opium with it, if it has a great tenden- 
cy to run off by the bowels. Friction with mercurial ointment, in 



HEPATITIS. 631 

the course of the absorbents, on the inside of the thighs, will also 
be advisable. 

When, therefore, you have reason to know that this important 
viscus is the seat of congestion, and the inflammatory symptoms 
have been subdued by the means pointed out, viz: venesection, 
purging, &c, mercury will be your great resource : you will direct 
it, 1. as an active cathartic and diaphoretic, as in the other phleg- 
masiae; 2d. to beget an inflammation in the mouth and salivary 
glands, and thereby to translate the inflammation from its original 
seat. But there is another, a third case of diseased liver, in which 
you will also have recourse to calomel; I mean as a diuretic, in 
combination with squills to remove the dropsical affections which 
are among the most usual consequences of an obstructed liver, in 
the manner suggested. But let me caution you against the abuse 
of this medicine, by employing it in dyspepsia instead of hepatitis; 
for as I have oftentimes observed, there is not only a connexion 
between the stomach and the liver, in its blood-vessels being 
branches of the same cceliac trunk, but in its nerves ; the stomach 
thereby partakes of the sufferings of the liver; the liver, too, is 
more or less affected sympathetically with the stomach, as in the 
cases of several gentlemen, all affected with dyspepsia, and not 
hepatitis; for all affection of the liver disappeared as soon as the 
stomach acquired tone from the chalybeates and other tonics 
which I advised. 

But as in peripneumony, so in hepatitis, you have a second 
stage as well as a first. In this the febrile symptoms are re- 
moved, the patient suffers no more pain, but remains debilitated; 
the liver is slow and torpid in its functions; the belly costive; 
countenance pale or sallow, wanting the florid complexion of 
health. Tonics are now indicated; the bitter infusion, tinctura 
amara, iron filings, and extract of gentian, Ballston waters, chaly- 
beate wine; iron in the form of acetate by giving it in cider in 
connexion with horse-radish, mustard seed, &c Nitric acid as 
used in the East Indies, is excellent in this stage. But in this stage 
of debility avoid calomel, excepting as a diuretic in case dropsical 
swellings are manifestly forming; then, too, be careful to pre- 
serve the tone of the system. Another remedy that you will find 
occasionally recommended in this disease and in the advanced 
stage of ;it too, is the cicuta, one of the most powerful narcotics 
that the Mat. Med. contains; yet in the opinion of its friends it is 



632 LECTURE LIII. 

to work miracles in unlocking the obstruction of this viscus. 
Delmas soberly proposed it, alleging that it is one of the best 
fendants or cleavers that the pharmacopoeia furnished. But be- 
ware of this fendant at this stage of the disease. 

The diet of the patient in these various stages, should also re- 
ceive the particular attention of the physician. In the first or ac- 
tive stage it should be as in membranous inflammation, equally 
antiphlogistic. While in the second stage it should be nutritious 
and moderately stimulating, viz: animal food, the stimulant con- 
diments of the table, and the moderate use of wine, and such 
drinks as will readily be evacuated from the system: gin and 
water, brandy and water, hard cider; but avoid porter, ale, and 
beer, &c; and exercise, especially riding on horse back, with the 
view of shaking the gall bladder, as Dr. Rush expressed it, 
speaking of the effects of an emetic in yellow fever. A journey 
or a voyage will also, with attention to diet, very much con- 
tribute to the recovery of the patient. But nothing can be more 
pernicious than a return to full feeding and the daily excessive 
use of spirituous and malted liquors; they will renew the very 
evils we have endeavoured to remove. But you will find a senti- 
ment of a very contrary nature entertained by many : they be- 
lieve that it is necessary, as it is vulgarly expressed, to keep the 
liver afloat, and therefore return to the very beverage, and the 
same excess, that produced the disease; that is, they continue to 
drink to cure the effect of drinking ! On the contrary, by the 
strictest temperance alone, can the patient find security against a 
return of his complaint, to which he will otherwise be much ex- 
posed. A single fact on this subject will be of more importance 
than any abstract principles, however they may be expressed. 
This I relate upon the authority of my old master, Dr. James 
Gregory: " Some British officers, some years since, fell into the 
hands of Tippoo Saib; he wanted them to enter into his service; 
they, like loyal subjects of the king, refused. The consequence 
was, they were detained three years in irons, and were in all re- 
spects treated with great severity. A handful of rice, boiled into 
gruel, was the daily ration allowanced to each. They were 
chained two and two. Several died of the wounds they had 
received in battle, and the dead bodies remained in some in- 
stances, fastened to the living until they fell into decay; none of 
them hoped to live long; yet they not only lived, but their liver 



HEPATITIS. 633 

complaints, under which, several of them laboured, and with 
which they came into prison, gradually disappeared; and when, 
after a long captivity, they returned to Calcutta, they found that 
many whom they had left well, had died of the very disease of 
which they had been cured, by the meagre fare prescribed by 
Tippoo Saib." So much for starvation as a cure of diseased 
livers. 



54* 



634 



LECTURE LIV. 

SPLENITIS, NEPHRITIS, HYSTERITIS, AND CYSTITIS, 

When speaking of hepatitis, I remarked, that when the sys- 
tem is unusually loaded with blood, certain parts of the body be- 
come surcharged, and may be considered as so many cisterns to 
the blood-vessels; at the same time too that the body has its waste 
pipes in the various excretions, which also serve to diminish in- 
ordinate plethora. The spleen is one of those sponges of the 
body, and is very apt to become thus surcharged. Hence we see 
it like the liver affected with inflammation, or, in other cases, a 
chronic fulness of that organ, vulgarly called an ague cake, and 
which frequently is the effect of long continued fevers, and the 
debility they produce. There are no characteristics of this dis- 
ease except the pain and tumor seated in the left hypochondrium, 
and pain shooting from the diaphragm to the left shoulder; there 
is sometimes a dry short cough, and sense of constriction about 
the praecordia. In nephitis the patient also complains of pain in 
the side, but it has its peculiar symptoms which distinguish it, as 
the retraction of the testicle, and the pain shooting along the ure- 
ters to the bladder, &c, and in females following the course of the 
round ligaments to the groin. Another disease with which it may 
hastily be confounded, is a spasmodic affection of the intestines, 
particularly the sigmoid flexure of the colon, in which lodg- 
ments of wind, or other contents of the bowels, in cases of cos- 
tiveness, frequently produce pain, that may be, for the moment, 
referred to the spleen or the kidney as its seat. The costiveness, 
the intermitting character of the pain, will very clearly designate 
the intestinal affection as different from an inflamed spleen. The 
causes of this disease are very similar to those of hepatitis and the 



NEPHRITIS. 635 

other phlegmasia; not only plethora, and the other predisposing 
causes, but the exciting, as cold, &c, and frequently the two dis- 
eases are associated. But among the most common causes of the 
chronic tumor of the spleen, are long continued intermitting or 
remitting fevers. Hence it is most frequently met with in those 
countries where those diseases are most prevalent. Splenitis, like 
the inflammation of the liver, may be divided into membranous 
and parenchymatous, but not chronic, inflammation of that organ . 
as Dr. Thomas calls it. A chronic tumor of that viscus may exist, 
and it is not unusual for such enlargements to become the seat of 
inflammation; and in some cases it has been known to proceed, 
like the liver, to suppuration, discharging itself externally, or in 
the cavity of the belly: in other instances it has been suddenly 
carried off by diarrhoea or hemorrhage, as other enlarged organs, 
the liver, uterus, &c. The treatment should be the same as in 
hepatitis* — antiphlogistic in the first stage of inflammation; tonics, 
as chalybeates, in passive tumors of that organ, attended w T ith 
debility. Calomel and iron it is to be remembered are among the 
best. But after the remarks we have made upon hepatitis, in 
its various forms, you can be at no loss in the treatment of a simi- 
lar inflammation or obstruction of the spleen. 

NEPHRITIS. 

Nephritis — inflammation of the kidney. The characteristics 
of this disease, according to Dr. Cullen, are, " Pyrexia; dolor in 
regione renis ssepe ureteris iter sequens; mictio frequens urinae, 
vei tenuis decoloris, vel rubeirimae; vomitus; cruris stupor; tes- 
ticuli ejusdam lateris retractio aut dolor. " The pain, too, fre- 
quently affects the small of the back, the neck of the bladder, and 
very generally the glans penis. In women the pain follows the 
course of the round ligaments to the groin, where they terminate 
and spread themselves. The urine, too, is in some instances not 
only very red, but more resembles the bright red arterial blood 
in a diluted state. The ratio symptomatum is called for in this 
disease as well as in hepatitis. How is the vomiting which so 
constantly attends upon nephritis to be accounted for? 1st. By 

* In India, where it is more common than in temperate climates, punctures 
and scarifications are much employed. 



636 LECTURE LIV. 

the general connexion that exists between the nervous system. 
Hence, pain in any sensible part is apt to affect the stomach, 
which so largely sympathises with the nervous system. 2d. We 
are to recollect that a very peculiar connexion exists between the 
stomach and kidneys, in consequence of the renal plexus being 
composed of nerves sent from the cceliac ganglia. 

How, again, do we account for the retraction of the testicle of 
the same side ? The spermatic nerves are derived in part, from 
the renal plenus — so also those of the round ligaments in females. 
This disease terminates in resolution, that is, where active mea- 
sures are taken, or large spontaneous discharges take place; or in 
suppuration, which is the most frequent. Either then terminating 
by a discharge of matter through the ureters into the bladder, or 
entering through the intestines and muscles in the back. In some 
few cases it ends in gangrene. 

CAUSES. 

In some instances this disease proceeds from cold, as its excit- 
ing cause; and especially attacks the full habit, and those who 
have previously been the subjects of it. Hence, it is one of the 
diseases attendant on a gouty habit of body, whether heredi- 
tary or acquired; for in both a plethoric state of the system 
usually constitutes a part of the disease. Yet in some instances 
there is also an acquired predominant lithiasis of the habit in 
which a redundancy of the uric or lithic acid becomes the excit- 
ing cause of nephritis, and if not the exciting, is at least a predis- 
posing cause. But in a child under my care, a quantity of this 
earthy matter was discharged in the process of its complaint; but 
the child was at first attacked with a pneumonic inflammation, 
from which it was recovering when it was attacked with nephri- 
tis. Here, then, caluclous matter in the kidneys was the exciting 
cause, as it proves in arthritic habits. In other instances acrid 
matters, such as cantharides, turpentine, balsams, beget inflamma- 
tion of that organ, especially when given in large doses. 

TREATMENT. 

Venesection, cupping, early, as no organ when inflamed, is so 
readily disposed to suppuration; saline cathartics. The warm bath, 



HYSTERITIS VEL METRITIS. 637 

fomentations, semicupium, open bowels, are especially useful as 
anti-spasmodics when a calculus may be passing. Dr. Gregory 
objects to salts, and recommends castor oil, manna, sulphur, senna, 
crem. tartar. Large enemata — blisters are of great benefit. There 
is no objection to their use, if you only avoid the injury they 
produce when badly prepared, or too long applied. Dr. Cul- 
len's objection to blisters is not well founded; nor is Dr. Tho- 
mas' mode of preventing the evil from them of any avail, viz: 
sprinkling camphor over them, nor a covering of gauze ! These 
also relax the kidneys — diaphoretics, sp. mind, and laudanum, 
Dover's powder — diuretics, nitrate of potash, and gum arab., soap 
alone, or soap and soda in equal parts. Dr. Bard used to give 
the soap in coffee. Emetics — magnesia, to keep the bowels 
easy. Digitalis — opiates large, every two hours. When the 
inflammation has terminated by suppuration and the symptoms of 
inflammation are removed, the balsams, chalybeates, chalybeate 
waters, the bark and other tonics are indicated. The leaves of 
the uva ursi are also highly recommended by Dr. Thomas and 
others, in this state of the urinary organs, 9i. to 3i. three times a 
day of the powder, or in tincture. The arbutus uva ursi is used 
more as an astringent to counteract the profuse discharges of mu- 
cus, as in the catarrhus vesicae. 

Drinks — diuretic and demulcent; barley water, flaxseed, musk- 
melon seeds, parsley root^ watermelon seeds, soda water, or §ss. of 
potash, ft)ij. water charged with fixed air. The food should be 
plain during the inflammation — regimen antiphlogistic during the 
active stage of the disease; to prevent its return — flannel next to 
the skin, occasionally warm bathing, warm feet. Avoid the com- 
mon practice of bathing the feet in w^arm water, as it renders them 
very sensible to cold; bathing in cold water, on the contrary, 
renders them warm and preserves an active circulation in the 
extremities. 



HYSTERITIS VEL METRITIS. 

Hysteritis, or inflammation of the womb. The term is derived 
from vstsga, the womb. This disease is characterised by pains, 
tension, swelling in the hypogastric region, extending to the 
groins and down the thighs; vomiting, hiccup, dysury or ischury, 
the os uteri painful to the touch, fever in some cases synochal, 



638 LECTURE LIV. 

in others typhoid. Great dispute has constantly existed about 
the nature of this disease, that is, as far as it is connected with 
puerperal fever, whether it be purely inflammatory or not. Dr. 
Young considered it as one of the putrid fevers, and a disease of 
debility; others as purely inflammatory. In private families in 
the upper walks of society, it is a simple inflammatory disease, a 
synochal fever; but in hospitals, and in the confined filthy apart- 
ments of the lower class of people, it assumes the typhoid type. 
Accordingly, whenever it has shown itself in the lying-in hospi- 
tals of Paris, Lyons, Dublin, London, Edinburgh, Aberdeen, and 
I may add New York, it has in many cases exhibited this last 
form of fever, and has been considered both a fatal and contagi- 
ous disease;* that is, the poison of typhus has spread fever, and 
attacking the lying-in women, an inflammation of the womb has 
been its accompaniment: and the disease has, in such institutions, 
only been arrested by evacuating the wards or houses, by free 
ventilation, by white-washing, cleaning the floors, bedding, fur- 
niture, and the other means of arresting the progress of typhus 
fever. In Edinburgh, in 1774, the disease was checked by these 
means by Dr. Young, then the obstetric professor. Similar pro- 
ceedings arrested the disease in Manchester, in 1800, as you will 
see stated, I think, by Dr. Hull, in his work on phlegmasia do- 
lens. (See p. 46, 8. See also Willan diseases of the skin, p. 516, 
vol. i. in which he speaks of the contagious puerperal fever. See 
also Pouteau's observations on the sam«e subject in the Memoirs 
de PAcad. des Sciences. See also Gordon on the same typhoid 
form of fever as it occurred in Aberdeen.) This has led me to 
divide the disease into two species, as I have done catarrh, and ton- 
sillitis, that is, into a simple inflammation of the womb, and that 
which assumes a malignant or typhoid character, hysteritis sim- 
plex, and hysteritis maligna. The first is characterised by syno- 
chal fever, the second by the symptoms of typhus superadded to 
the local inflammation of the womb. It comes on as the phleg- 
masia, generally with chills, attended with soreness, which is 
soon extended over the whole abdomen, which is painful to the 
touch; pain in the groins at the insertion of the round liga- 



* Of six hundred and fifty-three women delivered in one of the London lying- 
in hospitals, eighteen died of puerperal fever ; and of three thousand two hundred 
and six delivered in the lying-in hospital of Dublin, twenty -nine died. 



HYSTERITIS VEL METRITIS. 639 

ments; sometimes in one of the groins. The pulse, tongue, 
urine, are all different, depending on the circumstances under 
which it occurs, and the causes producing it, whether purely in- 
flammatory or typhoid. The milk is diminished, the breasts 
painful, the lochia checked, the respiration hurried and frequently 
anxious; the belly is swelled and remains so after the urine is 
passed; this distinguishes it from cystitis, with which alone it can 
be confounded, unless we also except peritonitis. It terminates 
by resolution. It terminates also in scirrhus; and in sphacelus, 
which is manifested by sudden relief from pain, cold sweats, cold 
extremities, tympanites, a livid countenance, an irregular pulse, 
now scarcely perceptible. Many trace all the complaints which 
supervene to their lying-in, to the injury then supposed to have 
been received. 

PREDISPOSING CAUSES. 

Great debility taking place in pregnancy, or during parturi- 
tion; by the great irritability accompanying it; inordinate disten- 
sion of the womb and peritoneum. 

EXCITING CAUSES. 

1. Cold. Checking the natural secretions, or the lochia. 2. 
Heat of the rooms. 3. Hot drinks, as it regards temperature; 
spirituous drinks; animal food; spices. 4. Much company; 5. 
Mismanagement during or immediately after parturition; tedious 
labour; violence in the use of instruments, or in the removal of 
the placenta j retention of the placenta after delivery. 6. Obsti- 
nate costiveness. 7. Fever; viz. milk fever; typhus fever ; 
scarlet fever. 

This leads me, too, to make another distinction into idiopathic 
and symptomatic hysteritis, as symptomatic of typhus. Hence 
it was called a contagious puerperal fever by Gordon, Young, &c. 
In this way, it lately prevailed in New Jersey,* supposed to be 
conveyed by the accoucheurs, as well as by other channels of 
communication. 

* Three years since, in Elizabethtown and the neighbouring country, in this 
city I have also met with it. (See Brewster's Cyclopedia. Notes to the article Me- 
dicine.) 



640 LECTURE LIV. 

8. In cases of pure hysteritis, it has sometimes been induced 
by violence during the honey-moon. I have seen cases in which 
it was induced by sexual intercourse. 9. Dysmonorrhoea. 10. 
The sudden suppression of the menses, and the natural cessation 
of the menses have both produced inflammation of the womb. It 
is said, too, to be more frequent with women who have never 
been with child than those who have. Scirrhus and ulcer are 
both the result; and there are many such cases where the pre- 
ceding inflammation is overlooked ; i. e. where the disease has 
been more particularly seated in the cellular and vascular part of 
the womb. In some cases, the scirrhus exists without inflamma- 
tion, as in the liver and spleen. Every tumour of these organs 
does not necessarily imply an inflammation of them, though pre- 
disposed to inflammation. 

TREATMENT. 

Venesection — but there must be caution when it is combined 
with typhus, or the patient is much debilitated. You must be 
governed by the condition of body, by the cause, and the evacua- 
tions she may have undergone. In idiopathic and pure hysteritis, 
a copious bloodletting is called for. Spontaneous hemorrhage or 
an inordinate flow of menses coming on has removed it. Fo- 
mentations of vinegar and water, not spirituous, semi-cupium. 
Open the bowels by calomel, gr. x. ; by salts, oil. Enemata daily, 
used as fomentations also. Calomel and antimony; antimonial 
solution; sp. mind, and laudanum; Dover's powder; opium is use- 
ful in inflammatory diseases, after venesection. It is recommended 
by Dr. Armstrong in most inflammatory diseases; and is especi- 
ally indicated where the inflammation is located in parts of great 
sensibility, as in the disease now under consideration. The 
breasts are to be drawn ; blisters should be applied early ; avoid 
emetics. Denman's antimonial mixture, however, is useful in the 
forming stage; but even then, nauseating doses are preferable — 
avoid bark. 

DIET. 

Drinks. — Teas; barley-water. Avoid heating, vinous, or spi- 
rituous drinks. Avoid spices and every thing exciting. 

Cases proceeding from the contagion of typhus, scarlatina, 



CYSTITIS. 641 

are to be healed accordingly by keeping in view the debility and 
prostration produced by that cause. Great caution is necessary 
in the use of the lancet. Greater attention should be given to 
the excretions, particularly those of the arteries, by antimonials; 
restoring the lochia when checked, or the menses when suppress- 
ed. These are to be solicited by fomentations to the abdomen, 
and by enemata. In cases of a tendency to gangrene, or sphace- 
lus, as occurs sometimes in inflammation from a retained placenta, 
use injections of yeast and water, thrown into the womb, or diluted 
muriatic acid. The air of the apartment should be purified — in 
an hospital especially — not forgetting all the ordinary means of 
guarding against the spread of contagion; ventilation; change of 
clothing. 

CYSTITIS. 

Pyrexia; hypogastrii tumor et dolor; mictiofrequensdolorifica 
vel ischuria; tenesmus. Fever, tumor and pain of the hypogas- 
trium, frequent and painful passage of the urine, or retention of 
it, with tenesmus. In some instances, if early and active measures 
be pursued, this disease, being seated in a mucous membrane, ends 
in resolution, in which case it goes off by a large secretion of mu- 
cus, as an ordinary catarrh. In other cases a purulent discharge 
takes place, after which also the patient may recover; but most 
usually, such is the sensibility of the bladder, and the violence or . 
rapidity of the disease, that it frequently terminates in sphacelus. 
When the inflammation is seated in the bas fond or lower part of the 
bladder the perineum is affected ; if in the neck, retention of 
urine, and constant effort to evacuate, but total inability; if the 
fundus, a stilicidium, unceasing dribbling; the bladder feels a sense 
of fulness, and the patient makes constant efforts, and the fundus, 
too, to get rid of it. 

CAUSES. 

One of the most powerful predisposing causes to this disease is 
the debility arising from age and intemperance. Hence, too, ple- 
thoric gouty habits of body are most liable to be affected with it; 
not only because they pass more earthy matter than other persons, 
but because of the worn-out or enfeebled state of the nervous sys- 
tem, and of those organs which so largely partake of it, together 
55 



642 



LECTURE LIV. 



with the pressure of the brain connected with fulness. The debi- 
lity, too, from excessive venery will have some effect upon the 
neighboring organs. 

EXCITING CAUSES. 

1. Over-distention of the bladder by retention of the urine. A 
patient of mine fell a victim to this disease, thus induced. He 
had been dining out, neglected to empty his bladder; inflamma- 
tion was the consequence of over-distention ; it ended in spha- 
celus. An aged gentleman in the neighbouring county, also sunk 
under the same disease, from retention of urine, the effect of cold, 
and the inability of three attending doctors, within thirty miles 
of the city, to draw off his urine. But this inflammation from 
retention is not always fatal. 

2. Pressure on the bladder by early pregnancy, producing 
retroversion of the uterus, which usually takes place about the 
third month, before the uterus rises out of the pelvis; it especially 
follows retention of urine in the first instance. Retroflexion is 
another cause of such injury after parturition, but is of rare occur- 
rence. 

3. Cantharides, either made use of internally or applied exter- 
nally after vesication is produced. For the most part a soreness 
only is occasioned ; but in other instances severe inflammation is 
the consequence. The turpentine may also in small quantities 
inflame the bladder in a full habit of body. Large quantities prove 
laxative, and therefore pass less readily by the kidneys. 

4. A calculus in the bladder, especially when the irritation it 
occasions is added to by intemperance, or by violent exercise. 
Dr. Franklin, when in Europe, and labouring under this disease, 
had occasion to get into a carriage, when he was furiously driven 
by a deaf coachman over a rough road, to his great annoyance 
and distress. Unable to stop his coachman by his loudest cries, the 
old gentleman at length reached his place of destination; when 
he left his carriage he swore, that never swore before, he would 
never enter another, unless he ascertained before hand that the 
driver had a stone also in his bladder. 

5. A badly treated gonorrhoea or urethritis is, in some instances, 
followed by inflammation of the bladder. I mean badly treated in 
two ways; either by a metastasis, i. e. suddenly removing the 
inflammation from the urethra by lead injections, or by the use of 



CYSTITIS. 643 

too stimulant or irritating injections, at the same time that no at- 
tention is paid to the diet and regimen of the patient. A fifth 
exciting cause of this disease is, mechanical injury to the bladder 
or its neighbouring parts. Strange as it may appear, I once attend- 
ed a young lady, ill of this disease, in which it was induced in a 
very extraordinary manner, by a blow on the pubes, which also 
injured the urethra, and, by the inflamation induced, interrupted 
the passage of urine. She was running down the kitchen stairs 
from the entry, her foot slipped, one leg went down, and caught 
her precisely in the notch of the pubes against the door; this was 
certainly a very unlucky stroke for the poor girl. But this was 
not all, her feelings were still more called upon: for I was obliged 
frequently to introduce the catheter before she obtained relief 
from the complaints induced; but she recovered without any per- 
manent bad consequences, either from the disease or the remedy 
employed. 

TREATMENT. 

Venesection large and repeated; cathartics, especially the 
saline; enemata frequently, and large, but not very stimulating; 
a warm bath, or the semicupium; fomentations, a bladder of warm 
water; blisters over the region of the bladder. The caution of 
Dr. Cullen, as before remarked, is unnecessary, only be careful 
not to continue the application after vesication is produced. 
Bedingfield remarks, that blisters applied near the urinary organs 
are not so apt to affect them with strangury as when applied 
upon parts at a distance. Diuretics, nitrate of potash, and 
gum arabic aa. gr. xv. sp. nitri dulcis, a small spoonful fre- 
quently, aided by diuretic and mucilaginous drinks. The 
catheter — which should be used two or three times a day, to 
prevent the distension which follows and adds to the inflamma- 
tion. The frequent introduction of the catheter also enables the 
bladder the sooner to recover its functions. I believe the neglect 
of this rule, or rather the want of it has been the great reason 
that the catheter becomes so necessary when it has been once 
employed. The bladder, as well as some other organs, is in this 
instance under the influence of habit. Do not, however, proceed 
to the other extreme, and keep it in the bladder; this again be- 
comes a source of fresh irritation by the accumulation of the 



644 LECTURE LIV. 

earthy deposits of the urine. Yet, in some instances, as in stric- 
tures, accretions on the catheter will not take place for some 
seven or eight days, sometimes more. Its being used occasion- 
ally, say once in two days, may prevent this effect. Cross says, 
once in four days. (See his account of the medical schools of 
Paris.) When it is attended with much inflammation and diffi- 
culty of introducing the catheter, we must leave it in, as the 
least of two evils; this is very necessary in such cases. Injec- 
tions of milk and water into the bladder, must be had recourse 
to frequently, to soothe the irritation. The uva ursi is very use- 
ful in counteracting the lax state of the mucous vessels of the 
bladder, which is otherwise apt to end in a catarrhus vesicae. 
The balsams also are useful to counteract such passive state of 
the parts; partial cold bathing may also be employed with 
advantage. 



645 



LECTURE LV. 

URETHRITIS, OR GONORRHCE A ;— ORCHITIS. 

Urethritis, or inflammation of the urethra, as its name im- 
ports. By this disease I do not mean gonorrhoea, which strictly 
signifies a seminal discharge. The application of it to the dis- 
ease now under consideration is certainly an abuse of the term, as 
inflammation characterises the one disease, and is in all instances 
wanting in the other. Urethritis is improperly placed by Dr. 
Cullen in the class locales. For all the phlegmasia^ might also, 
with equal propriety, be placed in that class as well as inflamma- 
tion of the urethra. Surely, ophthalmia, if urethritis, should be 
considered one of the locales. In my opinion, too, it is badly 
defined by Dr. Cullen; viz. "Three or four days after impure 
connexion, inflammation shows itself, and a puriform fluid, with 
dysuria, flows from the urethra." Saying nothing of the pre- 
ceding inflammation and fever, both of which usually attend upon 
this disease, and ought to receive attention, especially when placed 
in a class which dues not recognise either fever or inflammation. 

The seat of this disease, as we all know, like the eye, pos- 
sesses great sensibility; and hence active inflammation, and general 
febrile irritation, are to be looked for. 

The symptoms of this disease are so familiarly known to you, 
that I need not dwell long upon their enumeration. I may just 
remark, that they consist, in the first place, of a sense of fulness 
in the urinary passage, and an unusual degree of heat and irrita- 
tion at the time the urine passes through it. Such, too, is the 
degree of fulness in the mucous membrane, lining the urethra, 
that the passage itself is diminished; a general stricture exists 
upon it, and the stream of urine is frequently narrowed to a 
55* 



646 LECTURE LV. 

thread, or is forked. But the patient not only labours under ardor 
urinae; the pain and soreness extends to the neighbouring organs; 
it affects the neck of the bladder, producing a tenesmus of that 
organ; extends to the kidneys, producing not only pain in the 
back, but shooting down the ureters, with frequent calls to pass 
water. This excretion, too, is high coloured, from the increased 
excitement in the vessels of the kidneys, and which more saline 
condition of the urine probably, too, increases the heat and burn- 
ing attending the passage of it though the urethra. The testicles 
are also involved in the irritation. They frequently become ex- 
ceedingly painful to the touch, with occasional very severe pain 
shooting through them; and sometimes a retraction of them, as in 
other nephritic affections. Upon an erection taking place, the 
inflamed and enlarged urethra being put upon the stretch, very 
acute severe pain is necessarily the result, called chordee. This 
is very generally the attendant upon this disease, as the effect of 
the excitement in the parts, and the irritation of the bladder, 
occasioned by the high coloured urine, which is now secreted. 
With this symptom, too, there is also frequently great tenderness 
and irritation about the glands of the groin; and in some cases, 
buboes are produced, the effect of irritation. So also, in like 
manner, a phymosis, or a paraphymosis is produced; i. e. an un- 
usual tumour, and thickening of the prepuce, either involving 
or covering the glans penis, that it cannot be denuded, or the 
glans itself is protruded beyond it, and enlarged so that it cannot 
be withdrawn within the inflamed and thickened prepuce. But 
I may here remark, that both phymosis and paraphymosis are 
more frequently the attendants upon the chancres of syphilis than 
the inflammation of the urethra: and if not properly managed 
during the healing process, will leave the neck of the penis under 
a permanent ligature ; and if the sores be not properly cleansed, 
that are concealed behind the neck of the penis, the inflammation 
frequently ends in sphacelus of that important organ, and espe- 
cially the most important part of it. The whole system, too, 
becomes affected with synochal fever, depending for its degree 
upon the habit of body, the age, and other circumstances under 
which it oocurs. In the young subject, and where it is a first 
offence, the sufferings of the patient are usually more severe than 
in the hardened sinner, who has undergone frequent attacks of 
this disease. 



URETHRITIS. 647 

Urethritis I divide into two species. 1st. Urethritis maligna, 
arising from venereal poison, which is communicable. 2d. Be- 
nigna vel simplex, where it arises from other causes, as from 
gravel or gout, in which cases it is not communicable. This last 
form of the disease I have frequently met with in persons labour- 
ing under a gouty, that is, a full habit of body, and in those sub- 
ject to nephritic complaints. In these cases the inflammation 
appears to be produced by the saline and earthy materials which 
are frequently discharged in inordinate quantity, especially in the 
winter season, and the winter of life. In some instances, too, it 
is symptomatic of stricture in the urethra from preceding affec- 
tions of this nature. 



DIAGNOSIS. 

The only diseases with which this complaint can be con- 
founded, are, 1st. Gonorrhoea dormentium, or seminal discharges 
at night. 2d. Gonorrhoea mucosa, or gleet, the consequence of 
urethritis, or the attendants upon nephritic or gouty affections; 
and 3d. Syphilis — this last disease is invariably preceded by 
chancres. I have never met with gonorrhoea ending in pox; nor 
have I ever known pox to produce clap; and even though an 
ulcer be produced by the matter of gonorrhoea, no constitutional 
affection follows. In the Edin. Journal for July, 1815, you have 
absolute proof of this fact. Hunter and Thomas are certainly in 
error on this subject, considering these two diseases the same. 
Besides syphilis was known one hundred years before we hear of 
gonorrhoea. They are two totally distinct diseases in their na- 
ture and character, and require altogether a different treatment. 
In this, all the oldest practitioners of our city concur. From the 
time I entered practice to the present time, I have never em- 
ployed mercury in urethritis, and never had a patient to suffer a 
constitutional syphilitic affection, not in a single instance. 

The treatment must vary according to its two stages, the active 
or inflammatory, and the passive. In the first, venesection must 
be used, if the patient is of a full athletic habit. With active in- 
flammation, bloody urine, and febrile symptoms, leeches must be 
applied. Cathartics— salts to be preferred. Diuretics, nitre and 
gumarabic aa. gr. x.; warm bathing, tepid fomentations, washing 
the parts with warm water, injecting with the same; a sudorific 



648 LECTURE LV. 

anodyne; acescent and mucilaginous drinks, lemonade, barley 
water acidulated, flaxseed tea, soda water, cream of tartar with 
tamarinds; avoid wine, spice, animal food, especially while the 
chordee and other inflammatory symptoms remain. The opiate to 
allay this troublesome symptom, and other irritations, is no less 
useful than in ophthalmia; wine and other stimulants will produce 
this symptom. Make use of moderate exercise. Local reme- 
dies — injections of milk and water, warm water; a poultice of 
bread and milk; after a few days, during which period depleting 
means have been employed to reduce the inflammation and gene- 
ral febrile excitement, and these have subsided, then make use of 
an injection of the sulphate of zinc, from gr. ij. to gr. iv. to an 
ounce, five or six times a day. But of all things, let me advise 
you to avoid lead injections; as in ophthalmia they for a short 
time check the discharge; but heat and burning frequently 
follow, and the consequences are usually much worse than the 
original disease for which they were prescribed. The conse- 
quences are, swelled testicle, gleet and stricture. I have seen 
numerous cases of all these effects of lead injections. Cubebs, or 
the piper cubeba, has been very much used, in doses of from 3i. 
to 3iij. powder of the berries, two or three times a day; or from 
3i. to 3iij- of the tincture. I have no doubt of its utility in the 
passive stage of the inflammation of mucous surfaces. In that 
stage I should prefer it. Balsams also, are admissible only in the 
advanced or passive stage. 

One of the consequences thus induced, is inflammation of the 
testis, or orchitis. This disease is characterised by — 1st. A sense 
of fulness in the testicle, and tenderness to the touch, followed by 
a manifest swelling or enlargement. - 2d. Pain in the organ 
affected, and in the parts more immediately connected with it, 
extending along the cord to the abdomen, to the back, and par- 
ticularly affecting the kidneys. Even peritonitis has been in- 
duced as the effect of the irritation. In the case of J. R. the whole 
belly became tender to the touch, and demanded all the active 
treatment for its removal, as in idiopathic inflammation of the 
membrane lining the abdominal cavity. Inflammation of the tes- 
ticle has various terminations if not removed by active depletion, 
or transfer of the inflammation. 1st. Effusion of blood, or 
hematocele. 2d. Serous effusion, or hydrocele. 3d. Suppura- 
tion sometimes — this not frequent, Scirrhus enlargement very 



URETHRITIS. 649 

frequent. Sphacelus very rarely. The duration of the inflam- 
mation is generally such, and especially being seated in a secret- 
ing gland, that we have ample opportunity of removing the in- 
flammation by resolution, if those measures we employ, are judi- 
cious, and at the same time promptly made use of. The more 
common causes are, 1st. Cold. 2d. Mumps is not an unfrequent 
cause of this disease; but 3d. More usually a sudden removal of 
inflammation from the urethra, especially by lead injections, is 
the source of this disease. 



TREATMENT. 

1st. Venesection and leeches particularly useful. 2d. Open 
bowels. 3d. Emetics — John Hunter's explanation not well 
founded, except that they excite great relaxation, and restore the 
excretions of the whole system. As far as there is a connexion 
between the cseliac ganglia the renal plexus and the spermatics; 
the kidneys and testicles will be the first to experience the relax- 
ation to be desired in affections of those organs; but not acting 
by exciting particularly the absorbents of the testicles, but rather 
diminishing the flow of blood to that organ. 4th. Calomel and 
the pulvis antimonialis. 5th. Fomentations of vinegar and wa- 
ter; the application of tepid lead water and laudanum. 6th. 
Avoid cold applications; they add to the immediate sufferings of 
the patient, and indeed they oftentimes produce permanent in- 
jury to the part affected. I believe no practitioner would think 
of applying cold to an inflamed breast, or an inflamed uterus. I 
believe it to be equally improper to make use of cold applications 
to the testicle, or in ophthalmia. Dr. Ware, as I have already 
said, used warm applications in the latter years of his practice. 
Indeed in cases of uterine obstruction producing fluor albus, cold 
applied for the latter, invariably aggravates the former — an error 
of practice frequently committed by those who do not look to 
causes, but prescribe for symptoms — the hydra's head. 7th. 
Blister the part if the tumour remains obstinate. 8th. Be care- 
ful, too, to support the part by means of a suspensory bandage, 
especially when the patient is out of bed. 9th. Restore the dis- 
charge by the urethra, if it has been suddenly suppressed. For 
this purpose, make use of injections of warm milk and water. I 
have also, in some cases, brought back the soreness of the urethra 



650 LECTURE LV. 

by an injection of the corrosive sublimate, gr. i. to gr. ij. to an 
ounce, expressly to reproduce the inflammation, and thence to 
relieve the testis; if scirrhus be apprehended, repeat the blister; 
if the tumour remains torpid, involve the part in a — 11. Mercurial 
plaster — 12. And give calomel to excite the gums, and to 
quicken the absorbents of the part. The elm bark poultice has 
been found so beneficial in distressing and obstinate enlargement 
of the breast, it probably may be found no less beneficial in dis- 
cussing an analogous obstruction of the testicle. 

Gleet, or gonorrhoea mucosa, is also among the sequelae of 
neglected or mismanaged clap; that is, a relaxed or catarrhal state 
of the excretory vessels of the urethra and an increased and pre- 
ternatural discharge from them. Be careful, in the first place, to 
ascertain the fact, that gleet exists — erroneous impressions on this 
subject seize the minds of patients from want of correct informa- 
tion, by consulting books which they do not understand. A gen- 
tleman applied to me some years since, who was rendered 
wretched by the belief that he had this disease; he took many 
medicines without effect. Upon examining him, I found that no 
disease existed, except in his mind. His penis showed nothing 
more than the natural mucus that is to be forced off, especially in 
the morning. He was of course, very readily cured of his real 
disease, but not so soon of his imaginary gleet. In every in- 
stance, I mean in the male, (for females have fluor albus from 
other sources,) in which I have been consulted, this disease was 
the effect of lead injections made use of for urethritis. You must 
not be surprised after this fact, that I should altogether condemn 
lead injections in clap; for I know of no application which so 
relaxes the part affected, as this metal does; and indeed, when 
accidentally taken in the stomach in large quantities, that viscus 
never after regains its tone, nor the constitution its vigour. 

The remedies for gleet, as like chronic catarrh it is the effect 
of debility, will consist chiefly in the use of stimulants and 
tonics; chalybeates are among the best; iron and gentian; mineral 
waters; Peruvian bark; cold bathing, general and local; balsams; 
sp. terebinth, from one-half a teaspoonful to gss. three times a 
day; tine, cantharides, gtt. xv. to xxx. gtt. three and four 
times a day. Cubebs may also probably be used with advantage 
in this state of the parts; blister in perineo; injections of the 
sulphate of zinc, two, three, or four grains to an §j.; injections of 



URETHRITIS. 651 

corros. sub. gr. ij. to |j. A case was cured by injections of sea 
water. (Edinburgh Journal, July, 1815.) 

The diet should be generous and stimulating; animal food; 
condiments; mustard, horse-radish, cayenne; wine, madeira, port; 
gin and water. Exercise on horseback; a journey; moderate 
connexion with women, that is, lawful — this I suppose need not 
be urged upon you, except that it be moderate. Another evil 
consequent upon urethritis, and frequently upon the improper 
treatment of it, is stricture, or diminished diameter of the canal of 
the urethra, from neglect of this surface in its inflammatory stage. 
This appears in different parts of the urethra, from the glans 
penis to the bladder. It is very properly divided into temporary 
or spasmodic stricture, and permanent stricture, which last is 
usually the effect of inflammation, and consequent thickening of 
the membrane lining the urethra. The last is frequently met 
in any part of the passage of the urethra, and oftentimes within 
an inch or two of the glans penis; not so temporary or spasmodic 
stricture; this is more usually observed to take place in the mem- 
branous part of the urethra, where it is covered and acted upon 
by muscles, which stratum of muscles arises by a double tendon 
from the arch of the pubes, and unite under this part of the canal. 
These are described by Mr. Wilson. (See Med. Chir. Trans. 
vol. i.) Whether muscular fibres are found in other parts of the 
urethra or not, it is sufficient for our purposes to observe that 
such is the elasticity of this membrane that its diameter under- 
goes very considerable changes, sometimes admitting a large 
bougie to pass very easily, and then contracting almost 
upon a thread. This elasticity should not be forgotten when 
prescribing for stricture. (Monro, vol. iii. p. 13.) The causes 
of this form of the disease are cold; the excessive use of wine, 
or a debauch of any kind; the irritation from over distension of 
the bladder; the irritation of fever; cantharides from a blister; 
gravel. A case of stricture occurring in a child five or six years 
old, from gravel, is related by Andrews, in his treatise on stric- 
tures. In the adult it is not unusual, especially in winter, particularly 
from gravel; also in gouty habits from the same cause, especially 
too in the cold of winter, when an unusual quantity of earthy 
and saline materials pass by those channels, the kidneys ; and 
when permanent stricture exists, the effect of inflammation and 
actual thickening of the lining of the urethra, and a diminished 



652 LECTURE LV. 

diameter of the canal, these usual exciting causes of spasmodic 
stricture operate in renewing the paroxysms to which they are 
liable, and which, like the first, are also spasmodic, though the 
predisposing cause be a permanent impediment to a free dis- 
charge of urine. And I should add, these frequent renewals of 
irritation in some cases aggravate the original disease, and in 
some cases altogether close the passage. The remedies to be em- 
ployed must accordingly vary with the nature and extent of the 
disease. When a permanent thickening exists in the urethra, and 
there is danger of a total obstruction, a dilating bougie must be 
applied, and in some cases the application of a caustic must be 
introduced. In most instances, even where a degree of perma- 
nent stricture exists, you will meet with attacks of a spasmo- 
dic nature, and which are relieved by the means of allaying irri- 
tation without the introduction of a caustic, or a dilating bougie; 
and indeed, even, in many cases, without the introduction of a 
catheter. The remedies I refer to are, venesection; warm bath- 
ing; warm enemata; opium; tobacco injections; and injections of 
oil through the urethra. You may advantageously give the tinct. 
ferri. muriat. gtt. x. every ten or fifteen minutes. Antimonial 
medicines producing nausea have also relieved such impediments 
to the passage of urine. 



653 



LECTURE LVI 



CRURITIS, OR PHLEGMASIA DOLENS. 

Phlegmasia dolens is a disease which chiefly affects the lower 
extremities of lying-in women, and which usually appears a short 
time after parturition. Hence the various appellations given to 
it in different countries, as a disease attendant upon parturition, 
or, as connected with the appearance of the milk and its supposed 
sudden translation to the limb affected. Dr. White, of Manches- 
ter, who wrote the first regular treatise on this subject, denomi- 
nated this disease, phlegmasia alba dolens puerperarum, i. e. the 
swelling of the lower extremities of lying-in women. The French, 
too, call it, "Fenflure des jambes et des cuisses de la femme ac- 
couchee." By the French also it is sometimes called "depot du 
lait;" and by the Germans, oedema lacteum, the milk leg, and 
milch streichen. Dummer calls it the swelled leg ; Good, bucne- 
mia, of which he makes two species, viz: bucnemia sparganosis, 
i. e. the puerperal tumid leg; and 2d. bucnemia tropica, or the 
tumid leg of hot climates, the Barbadoes leg, or elephant leg ; 
with propriety are both introduced by Good. Dr. White published 
his inquiry on this subject in 1784; this was the first publication 
that appeared in the shape of a regularly digested treatise or essay 
on this subject. It was described by Dioscorides, under the ap- 
pellation of sparganosis, from the verb, $*apyaw, to tumefy and 
distend; a term adopted by Good, and appropriated to this affec- 
tion. Dioscorides used it in a more extensive sense, as applicable 
even to some affections of the chest. A case of it was described 
by Rodriges Decastro, of Hamburgh, in 1603, in which he attri- 
buted the disease to the scantiness of the lochia. I may also refer 
you to the account of the apothecary, noticed by Wiseman, in 
56 



654 LECTURE LVI. 

1676, or the observations on this subject by Mauriceau, in 1712, 
and by whom this disease is ascribed to a reflux of the lochia 
upon the limb — "depot laiteux sur la cuisse." Mesnard, 1743, 
ascribes it to the suppression of the lochia, and the consequent ar- 
rest and coagulation of lymph in the parts affected. (See Guide des 
Accoucheurs. Paris, 1743.) Puzot, of Paris, too, in his works, 
published in 1759, six years after his death ; Levrett, also, in a 
memoir in the Journal de Medecine de Paris, for July; and As- 
true, 1761, who imputes it to the lymph being thickened by an 
admixture of milk, in consequence of which it cannot pass 
through the glands, but stagnates in them. Sauvages, two years 
after, in 1763, in his Nosologic Methodique, speaks of it under 
the appellation of phlegmasie lactee, in his class of cachexias, i. e. 
considering it as one of the vitiations of the system, or vices of 
the habit. In 1784, a more full display of the character of this 
disease was drawn up by that able practitioner, Dr. White, of 
Manchester; since his time we have also the instructive writings 
on this subject of Dr. Frye, of Gloucester, who published in 1792. 
Their doctrine, both White and Frye, is an obstruction or other 
morbid state of the lymphatics of the limb. (See vol. xiii. ) Dr. 
Ferrier, in his Histories and Reflections, and Dr. Hull, of Man- 
chester, have also written well. In Dr. Denman's work, too, you 
find an instructive chapter on the same subject, published in 1800. 
Hull's theory, in his own words, is this: " The proximate cause 
consists in an inflammatory affection, producing suddenly a con- 
siderable effusion of serum, and coagulated lymph from the exha- 
lents into the cellular membrane of the limb. The seat of the in- 
flammation I believe to be in the muscles, cellular membrane, and 
inferior surface of the cutis. In some cases, perhaps, the inflam- 
mation may be communicated from those parts to the large blood 
vessels, nerves, and the lymphatic vessels and glands imbedded 
in them." This is the most correct view. It is, however, a dis- 
ease not of very frequent occurrence ; but it is one attended with 
so much immediate suffering to the patient, and occasionally is 
succeeded by so great debility and other diseases, that it demands 
your attention. Of 1897 women delivered in the Westminster 
Dispensary, five only were attacked with it. Of 8000 at the 
Manchester Lying-in Hospital, and at their own houses, only 
four. Dr. Thomas tells you that in thirty years' practice he had 
seen but one case, and but two in thirty -five years. I have seen 



CRURITIS. 655 

five cases since the year 1794. It is a disease generally confined 
to the puerperal state, but not exclusively; most usually so after 
labour at the full time, or premature labour. Cases are recorded 
in which it has taken place in young unmarried women ; in old 
women, after the period of parturition, and indeed in old men as 
well as old women. Mr. Sankey, surgeon, of Wingham, in Kent, 
relates, in the tenth volume, (p. 401.) of the Edinburgh Journal, 
two cases occurring in young women, not after or connected with 
parturition. In both, the disease was severe and well marked; in 
both cases the menses were obstructed, and one had suppression 
of urine. He also states a well marked case of a man, sixty years 
old.* His remedies were laxatives, opiates, blisters, first to the 
calf of the leg, afterwards, every two or three days, higher or 
lower, according as the pain was situated. 

These diseases, Mr. Sankey observes, were never fatal, though 
oftentimes tedious and painful. In most of his patients, too, he 
remarks, that both legs were affected in succession. Dr. Thomas 
saw it in an old woman; and a case is related by Levret, in 
which the disease took place a year after delivery. t One of the 
last cases in which I saw this disease, took place twenty-three 
days after delivery, and several days after the lochial discharges 
had totally ceased. This is an important fact, and we shall find 
it destructive of that theory of Dr. Darwin and Mr. Frye, and 
others, which ascribes the disease to the lochial discharge as 
attendant upon parturition. A single fact will thus oftentimes 
vanquish a volume of speculation. For the most part, however, 
we know that this disease is met with in the puerperal state, 
though not extensively so. I have accordingly, when describing 
its characteristic symptoms, remarked that it chiefly affects lying- 
in women; and I may add, it generally occurs during the dis- 
charge of the lochia, say from the fifth or sixth day to two or 
three weeks after delivery. Dr. Bard states it as taking place 
from the first or second day, to two or three weeks after delivery. 

* Other cases may be seen in the volume of the Med. Chir. Trans, for 1819, 
in which this disease took place in the male as well as the female, and in the un- 
impregnated as well as the married. (Recorder, No. ix. p. 125.) Case in a male, 
by Dr. Denmark, Med. Chir. Journal, July 1817. In some of these cases they 
very probably were confounded with ordinary rheumatism, to which they bear 
close resemblance. 

t A case is related by Dr. Dickson in which "the uterine discharges had 
almost ceased entirely." (Am. Recorder, No, 9, p. 115.) 



656 LECTURE LVI. 

A case is related by Dr. Dickson, as occurring on the fourth day- 
after delivery. (Am. Recorder, No. 9, p. 115.) Dr. Denman 
dates the period of its attack from the fifth or sixth day to the third 
or fourth week; but he adds that it most commonly occurs be- 
tween the fifth and twelfth day. Dr. Caspar says from the 
eleventh to the fifteenth. 

We may consider it as an inflammatory disease of the limb or 
limbs affected. Most usually one limb is affected; sometimes 
both at the same time; sometimes both in succession. It is 
usually described as commencing with symptoms of general de- 
pression, loss of spirits and great irritability of mind and body, 
analogous to the depression arising from the poison of typhus 
fever first acting on the system. Sometimes, says Dr. Ferrier, it 
is ushered in by chills. 

2d. The patient at the same time, says Dr. Denman, feels irri- 
tation, soreness, and occasionally pains about the uterus and 
groins. These symptoms are to be expected in every lying-in 
woman, and upon every invasion of fever, whatever may be its 
type. Those symptoms and feelings predict this disease, says 
Dr. Denman. I say that these uterine and nervous affections 
sometimes follow the disease; for according to Dr. Ferrier, it 
sometimes begins not in the groins, but in the knee and legs; and 
in one case referred to by Dr. Hull, the whole limb was affected 
at the same time. 

3d. The pain is acute and sudden at first, in the calf of the leg, 
extending to the heel on the inside, and reaching to the groin, ob- 
serving the course of the lymphatics. The inguinal glands, both 
the external and superficial, and the internal and deeper seated, 
become painful, swelled, indurated, and very sensible to the touch. 
In some cases, both chains of glands are affected. The lympha- 
tics do not always show by their appearance that they are in- 
flamed; but sometimes, according to Dr. Ferrier, this is mani- 
festly the case, and knots are occasionally to be felt in the course 
of the lymphatics. The limb over its whole surface, especially 
on the inside of it, becomes very sensible to the touch, and very 
painful upon the slightest movement, even to torture and fainting, 
precisely as in the most painful forms of acute rheumatism — as it 
enlarges it becomes pale and glossy, as in dropsy; and in some 
cases, such is the congestion that occasionally occurs, the limb 
becomes as hard as marble. Such is the determination to the 



CRURITIS. 657 

part affected, the countenance, too, is pale, as in other inflamma- 
tory diseases. 

4th. A manifest increase of fever now ensues, attended with a 
corded and frequent pulse, as is common in inflammation of the 
dense or serous membranes. The tongue white, accompanied 
with great thirst; the skin dry and hot; the limb is also preter- 
naturally heated; the urine high coloured, and soon observed to 
be muddy and small in quantity, as in dropsy; the belly is cos- 
tive; the stools of a pale clay colour, indicating the diminished 
secretion of bile; the secretions are in general diminished; the 
milk ceases to flow, or is sensibly lessened; the lochia, too, are 
lessened or checked altogether ; or if the discharge be continued, 
they are offensive, which, it may be remarked, is always the case 
in a febrile state of body, whatever may be the character of the 
fever present, whether milk fever or any other. 

Dr. Denman remarks that this offensive state of the lochia 
has frequently been observed to exist in a much greater degree 
before the attack of this disease than is usual; i. e. I should say, 
a febrile state in a less degree may exist, rendering the discharges 
more offensive; or the discharges may have been profuse from 
other circumstances, and thus be rendered unusually offensive. 
But it does not follow that offensive lochial discharges beget this 
disease, as stated by Dr. Denman. This is certainly bad logic. 
I should just as readily attribute the milk fever to offensive lochia 
as this disease of the limbs to that source. 

5th. The febrile symptoms begin in about twenty-four hours 
after the pain in the limb begins; the leg and thigh begin to swell; 
a great determination takes place to the part affected; the whole 
limb becomes of an enormous size. The swelling having taken 
place to this extent, the pain abates, probably from compression 
of the nerves, as in other parts of the body, from plethora; the 
limb, too, is benumbed and stiff. 

Some writers ascribe this change to a rupture taking place in 
the lymphatics, forgetting that these vessels possess a very re- 
markable degree of strength; and that even the pressure of a 
tourniquet never ruptures a lymphatic. They forget, too, their 
remarkable resistance to the pressure of a column of mercury 
when forcibly injected into them. Others, too, and among these 
are Denman and White, suppose that a sort of aneurismal enlarge- 
ment takes place in the smaller lymphatics, by which they take 
56* 



658 LECTURE LVI. 

off the load distending the larger. This may be proof of the 
powers of their imagination, but will not be considered as the 
evidence of the fact. It shows how riotous and maniacal the 
imagination becomes when a new hypothesis is to be supported. 

Another party suppose this rupture or laceration of the lym- 
phatics to arise from the great pressure made upon the sharp edges 
of the pelvis by the head of the child, and the violence of labour! 
On the other hand, it is notorious, as Dr. Lowder observes, that 
this disease takes place after easy labours as well as violent ones. 

But the tumour is not exclusively confined to that part of the 
limb in which the lymphatics abound. The whole limb is in- 
volved in the disease, from the very toes to the abdomen, includ- 
ing the labia pudendi, even extending to the nates and loins. The 
patient is incapable of voluntary motion, in the first stage, on 
account of the acute sufferings it occasions: in the latter, from the 
benumbed, paralytic state of the limb. 

6th. After eight or ten days an abatement of the most urgent 
symptoms takes place. The swelling, however, as Dr. Denman 
observes, to a certain extent, may remain weeks, and even months. 
In this it is analogous to gout and rheumatism, especially if not 
actively treated by depleting remedies; and as in gout and rheu- 
matism, the disease, after appearing in one limb, is transferred to 
the other, especially if the antiphlogistic treatment be not vigor- 
ously pursued. In one case, related by Dr. Dickson, uterine 
hemorrhage supervened, and proved fatal. (American Recorder, 
No. 9, p. 115.) This fact also shows the inflammatory character 
of the disease, and the increased action it produces in the blood- 
vessels. In some cases, it is said to have left a permanent dis- 
ease of the limb, both of enlargement and debility. (See Med. and 
Chir. Trans. Vol. ii. p. 66.) Upon dissection, no change is seen 
in the bones or muscles, but in the skin and adipose membrane; 
these were one inch and a half thick; the papillae of the cutis 
were sensibly enlarged, as in real elephantiasis. (See ibid. p. 70.) 

In the case, too, of Mrs. C. the limb remains enlarged; and 
such is the fulness and tumour, that it is even painful to the touch, 
though many years have passed since she was affected with the 
disease. Thomas, indeed, says that the limb seldom, if ever, 
returns to its former size. This is not true. On this subject he 
is no authority, for he acknowledges he has seen but two or three 
cases of it. From the same cause, too, he has been led into the 



CRURITIS. 659 

error that it is a purely local disease, which idea he expresses in 
so many words. In some cases, too, it is said to have ended 
fatally. Both Dr. Hull and Denman state this fact. A case is 
also related, in which it proved fatal. (See Med. Museum. Com- 
munications of the Royal Society at Goettingen. Trans. Vol. i. 
p. 335. Med. Chir. Trans. Vol. xii. p. 424.) 

These permanent consequences, or fatal terminations of the 
disease, are certainly of rare occurrence, except as the effects of 
mismanagement, or the disease occurring under great debility of 
constitution. In some instances, too, it has terminated in suppu- 
ration. (See Hull.) But mostly the disease, like rheumatism, 
ends in effusion ; and after some length of time, a reabsorption of 
the effused fluid. 



CAUSES OF THE DISEASE. 

The predisposition to this complaint, particularly in the puer- 
peral state, appears to be the debility of the limb, from the long 
continued pressure produced by the pregnant womb, and fulness 
of the vessels resisting the ready return of blood from the lower 
extremities. A case related in the Medical Chirurgical Trans. 
Vol. ii. p. 69, in which this diseased state of the limb took place 
after the cessation of the menses, shows the influence of plethora, 
in predisposing to this complaint. A fact, too, showing the con- 
nexion between plethora and this disease, is, that of fourteen cases 
recorded by Mr. White, eight did not suckle their infants. 
The general irritability of frame, in the lying-in woman, and of 
the lower extremities also, in a peculiar manner, renders her liable 
at this time, to inflammatory diseases. A former attack particu- 
larly predisposes to a second. 

Most writers appear to agree in the opinion, that the disease 
has its principal seat in the lymphatics of the limb, or at least that 
it especially affects those parts. But this, we shall show you, is 
not the part of the limb primarily affected, and, indeed, that the 
lymphatics are not necessarily affected, to constitute this disease. 
Mr. White, one of the earliest writers on this subject, considers 
the disease to consist in an obstruction, detention and accumula- 
tion, of lymph in the limb, and that this is occasioned by accident 
in labour, or during pregnancy, and that it is peculiar to child- 
bed. He believes that the head of the foetus pressing upon the 



660 LECTURE LVI. 

sharp edge of the pelvis, ruptures the lymphatics of the limb. 
There is certainly no proof of this. During pregnancy it is well 
known, that no such pressure can take place; besides, as already 
observed, this disease sometimes occurs after easy labours, as well 
as those which are more difficult or tedious; so says Dr. Ferrier. 
And, if this opinion were well founded, that pressure was the 
cause, the disease should appear earlier, certainly at parturition 
or immediately after it, when the pressure had just been expe- 
rienced ; not so is the fact. Besides, no enlargement of the limb 
followed the obstructed glands in the cases related by Mr. Aber- 
nethy, nor does it happen in ordinary affections of those glands. 
Frye, of Gloucester, in 1792, another eminent writer on phleg- 
masia dolens, ascribes the disease to obstruction of the lymphatics, 
produced by inflammation of one or more of their trunks, occa- 
sioned by pressure, or by the absorption of some acrid humour. 
This doctrine, particularly the last opinion, has been adopted by 
Dr. Denman and by Dr. Bard, that the disease arises from an 
absorption of the acrid discharges of the uterus, affecting first 
the glands in the pelvis, and at the upper part of the thigh ! 
There are several insuperable objections to this opinion. Upon 
this principle it should, 1st. occur more frequently, as such offen- 
sive discharges are ever flowing, whereas the disease may be said 
to be of comparatively rare occurrence. 2d. It should be the 
attendant on diseases of the womb, especially an ulcerated or can- 
cerous state of the uterus, whereas this does not take place. It 
has occurred where there has been no morbid action of the 
menses or mammae, and so where all the secretions have been 
flowing in a healthy state in quality and quantity. (See also 
Good, vol. 2, p. 4 IS.) 3d. The disease should always commence 
in the groins and about the pelvis. This is not the case. Certainly 
it generally affects the calf of the leg first; and in the case of Mrs. 
M. it attacked her twenty-three days after parturition, several 
days after the lochia had ceased. 4th. Again, Dr. Ferrier states 
that it exists independently of parturition, that in some cases it 
is produced before delivery. He believes that it is occasioned by 
pressure on the internal iliacs, and accompanying veins and 
nerves, producing lymphatic imflammation, without rupturing 
the lymphatics, and that the sensibility being greater then than 
under other circumstances throughout the whole limb, renders it 
peculiarly liable to inflammation. This is a nearer approach to 



CRURITIS. 661 

the truth than any of the views heretofore taken of this subject. 
Dr. Thomas also mentions a case in an old woman unconnected 
with parturition. I have also certainly seen rheumatic enlarge- 
ments of the limb so like that of puerperal women, that it would 
puzzle Dr. Denman himself, or any other physician, to distin- 
guish them. Dr. Hull, a still later writer, has generally, in my 
opinion, taken the most correct view of the nature of this disease. 
He rejects all the preceding theories. His predisposing causes are 
two: — 1st. increased irritability attendant on pregnancy, and still 
more so immediately after parturition. 2d. An over distended 
state of the vessels of the lower extremity and lower part of the 
trunk. The exciting causes enumerated by Dr. Hull are, 1st. 
Contusions, or violent exertion of the muscles of the thighs or 
pelvis; but of these contusions or exertions there appears no evi- 
dence. 2d. Plethora, from suppression of the lochia, or the 
milk; too much animal food, spices, wine, &c. 3d. Food taken 
too freely — and he should have added, of improper quality — such 
as is calculated to excite the system. In the case of Mrs. C. it 
was induced by an error of the physician, directing her to drink 
two bottles of wine a day, after her lying in! ! ! It was, in her 
case, a wine leg! 4th. Standing or walking too much, and too 
early after delivery. 

In these views of the subject, Dr. Hull certainly has enume- 
rated some of the agents concerned in the production of the dis- 
ease; but he should have added cold, and other causes producing 
fever. The general and local irritability, both predispose to such 
inflammation, as well as that of the breasts or the uterus; espe- 
cially after great distension of the abdomen, and perhaps a violent 
labour, or in the case I have already referred to, Mrs. M., in 
which it occurred after the lochia had ceased, the lady had borne 
two children, and both large. Her labour, too, was severe, and 
followed with great hemorrhage. In this case great distension, 
a violent labour, and hemorrhage, all concurred in predisposing 
to this disease — it was excited afterwards by cold. 

The proximate cause, according to Dr. Hull, consists in an 
inflammation of the limb, producing effusion into the cellular 
membrance, as the consequence. He supposes, also, a great con- 
nexion to exist between phlegmasia dolens, peritonitis, and puerpe- 
ral fever, &c. This Dr. Thomas denies. The truth is, the same 



662 LECTURE LVI. 

causes which produce the one will produce the other. So far 
they are connected. 

Dr. Hull relates eight cases, in which no enlargemnnt of the 
lymphatics whatever occurred. He therefore very properly con- 
siders the lymphatic obstruction as a consequence, not as a cause, 
and therefore not necessarily a part of the disease; and which he 
considers to be an inflammatory affection of the limb, and that 
this effusion of coagulable lymph takes place in this as in other 
inflammations. Let me repeat the idea I have already expressed, 
that in the lying-in woman there are three parts of her system 
more irritable than the rest, and consequently more liable to become 
the seat of disease; viz. the uterus and peritoneum, the breasts, 
and the lower extremities. The limbs, I may add, appear to be 
the least liable of the three to be affected; consequently this dis- 
ease is of more rare occurrence than either affections of the womb 
or of the breast. 

The predisposition insisted on by Dr. Ferrier ; viz. an inter- 
rupted circulation, and increased irritability, is doubtless correct. 
This irritability, in consequence of weakness, is denominated by 
Mr. Hunter, "the stimulus of relaxation." It is particularly 
illustrated in this disease, for the vessels of the limb having lost 
their distension, which they possessed during pregnancy, are 
now peculiarly languid in the circulation of the blood; accumula- 
tion is the result, and inflammation. But this relaxation is not con- 
fined to the lymphatics, as supposed by many; and I observe, too, 
by Dr. Good. (See p. 477.) And it is very possible, that the 
exciting causes, mentioned by Dr. Hull, are correctly stated; but 
to those should be added cold, which I believe to be the most 
frequent of all the exciting causes. In one of the cases I saw, it 
came on manifestly thus excited. It came on with cough, fever, 
and ehill, affecting the chest with difficulty of breathing, inso- 
much that her friends were all sensible of her having taken cold. 
The same thing appeared in one of the cases, related by Dr. Davis 
— the woman died — the chest was in a state of inflammation as well 
as the limb. (Med. Chir. Jour. vol. 12.) It soon, by metastasis, 
seized the lower extremities, where it was exclusively confined. In 
all it appears in the usual way. Ordinary inflammatory diseases 
appear, and with chills. Dr. Ferrier also states some cases of this 
disease to be manifestly thus produced. Dr. Hull relates the 
case of a corpulent man leaping from a high fence, being thus 



CRURITIS. 663 

affected by mechanical injury. Dr. Ferrier, too, notices a case 
occurring spontaneously in a man of full habit of body, who was 
subject to frequent bilious attacks — both probably from the same 
cause, plethora. 

TREATMENT. 

The remedies to be employed must be general and local. Ve- 
nesection is called for, but is to be used cautiously. Emetics also 
are useful in this complaint, as are also cathartics, especially the 
saline purgatives, and enemata. Sudorific anodynes are called 
for, such as the Dover's powder, and the spiritus mind, and laud- 
anum. Diuretics also may be advantageously used; and among 
the best of these are calomel and squills. Begin with one grain 
of each, night and morning, or three times a day, aiding the ope- 
ration of the medicine by diluent drinks. The tincture of the 
colchicum autumnale may probably be usefully prescribed in this 
affection, as well as in gout and rheumatism, and especially in its 
first stage. 

The local remedies must consist chiefly of warm fomentations 
of vinegar and water, or of poppy heads steeped in vinegar: 
leeches, cupping, blisters, or issues. Soft poultices, too, will be 
found useful, applied morning and evening. 

But when the febrile symptoms have abated, and the local in- 
flammation has disappeared, there remain only debility, and per- 
haps oedema. Then apply a flannel roller to the limb; and use 
spirituous, and other stimulating applications, to the part Use 
friction with the flesh-brush or the hand. This is especially im- 
portant to excite the languid circulation in the vessels, and to 
give tone and activity to the absorbents. 

Frye recommends the mercurial ointment; and others small 
doses of calomel. These, however, should be avoided in the first 
stage, especially if the patient is much enfeebled. Dr. Good ob- 
serves that he has seen them produce great mischief in such cases. 

The diet and regimen must be regulated upon the principles 
observed in the other phlegmasia?. With these you are now well 
acquainted. 



664 



LECTURE LVIL 



RHEUMATISMUS VEL MYITIS. 



Rheumatism, the myitis of Crichton, thereby denoting the 
seat of this disease to be chiefly in the muscles. By Dr. Parr the 
old name of arthritis is retained, which by the ancients was ap- 
plied both to gout and rheumatism. It is important that they 
should be separated, both as it regards their nature and their 
treatment. With this view too, Dr. Parr annexes to the term 
arthritis, the adjunct rheumatismus; gout he calls arthritis poda- 
gra. I have retained the term rheumatism, as pretty generally 
agreed upon among writers. It is so called from rheuma, (from 
the verb psw, fluo,) denoting a defluxion on the part affected; and 
answers the purpose as well an any other name proposed; and 
has this advantage, that it is well understood. Dr. Cullen's de- 
finition contains many details, viz. " morbus ab externa, et ple- 
rumque evidente causa; pyrexia; dolor circa articulos, musculo- 
rum tractun sequens; genua, et reliquos majores, potius quam 
pedum vel manuum, articulos, infestans, calore externo auctus." 
He intends by the first part of this definition to distinguish it 
from gout; but this is not the place for diagnosis. A definition 
should contain only the characteristic symptoms of a disease. 
The first part of his definition is not invariably true, that it pro- 
ceeds, (in all cases,) from an external cause; nor is the last uni- 
formly true, that it is increased by external heat. Besides, these 
circumstances are equally true of any of the phlegmasia?; they 
are applicable to gout as well as to rheumatism, for gout fre- 
quently, like rheumatism, is excited by cold; and, like rheuma- 
tism, is increased by heat. Rheumatism, acute, Dr. Home ob- 
serves, is more frequent in summer than winter; attacks more 



RHEUMATISMUS VEL MYITIS. 665 

females than males; that it is rather a nervous than inflammatory- 
disease; that antispasmodics are most effectual in curing it, 
but, by the by, venesection is the best antispasmodic; that of 
twenty- two patients in the infirmary with it, sixteen were females; 
that he has more in summer than winter; but his observations 
are made at the infirmary. Query: Are there not some circum- 
stances probably overlooked, which, will otherwise account for 
these occurrences, so contrary to general observation? That it is 
not the heat of the bed which aggravates the disease more at 
night, but what he calls a nocturnal paroxysm, observing that the 
patients with it are always in dread. This same remark will ex- 
tend to most inflammatory diseases. 

Another exception to Dr. Cullen's definition is, that it is not 
confined to the joints: on the contrary it frequently affects the 
muscles of the head, of the chest, of the abdomen, and even the 
viscera, as well as the joints; and it affects the small joints as 
well as the larger. I know a lady, afflicted with a rheumatism, 
who had large deposits of chalky matter, similar to those of gout. 
Dr. Gregory has also frequently made this observation, that rheu- 
matism affects the small as well as the larger joints; that he has 
seen the fingers crooked with it, and then of course incurable. 
Dr. Cullen, therefore, should have added the qualifying expres- 
sion, " plerumque," after " dolor." Indeed, rheumatism might 
be defined to be an inflammatory disease of the muscles, (includ- 
ing their fasciae, or inclosing membranes,) and the membranes 
composing and surrounding the joints. And like the inflamma- 
tion of some of the viscera, it might also admit of the distinction 
into membranous and parenchymatous, showing by the former, 
that the disease is more immediately seated in the membranous 
portions and coverings of the muscles, and of the joints; and that 
the latter more especially affects the strictly muscular and cellular 
portions of the muscles; and in which the pain and febrile symp- 
toms are relatively less accute, which sometimes terminates in 
abscess. In the definition in my nosology, I have accordingly 
adverted to these particulars. Read there my definition of rheu- 
matism. In my definition of species, I have complied with cus- 
tom in dividing it into acute and chronic. Yet I wish it to be 
understood that I consider chronic rheumatism, as chiefly the 
sequela of the former; a morbid sensibility that remains in the 
part after the acute or febrile rheumatism has run through its 
57 



666 LECTTTRE LVII. 

course, and the evidences of general excitement have subsided? 
as scifrhus succeeds to inflammation. Accordingly Dr. Cullen 
places chronic rheumatism under a distinct head of arthrodynia 
or pain of the joints; and considers it, very properly, among the 
consequences or terminations of rheumatism; and which he thus 
defines: "Post rheumatismum, nisum violentum, vel subluxa- 
tionem; dolores artuum vel musculorum, sub motu prsesertim, 
aucti plus minusve fugaces, calore lecti vel alio externo levati; 
artus debiles, rigidi, facile, et ssepe sponte frigescenter; pyrexia 
nulla; tumor plerumque nullus." 

Some allege that rheumatism sometimes takes place from the 
presence of an inordinate quantity of lithic matter in the system. 
The phenomena arising from this supposed cause, are more satis- 
factorily to be explained by the interrupted state of the excre- 
tions, and the febricula such interruption produces, attended with 
pain, and other irritations of the debilitated sensitive system ; for 
these occur most usually in advanced life. And from the same 
causes, the impaired state of the excretions, we may account for 
the inordinate deposit of earthy matter in different parts of the 
body. 

The symptoms of accute rheumatism are those of the phleg- 
masiae in general. It usually comes on with chills, succeeded by 
great heat, with pain in the limbs, changing its seat from one joint 
to another, and is especially increased by the heat of the bed, 
and occasionally attended with great soreness to the touch of the 
surface as well as of the internal parts. The pulse is hard and 
frequent ; the tongue white and furred, with great thirst. The 
secretions are generally interrupted; the urine appears pale; after- 
wards becomes high coloured, depositing a large lateritious sedi- 
ment, as in gout ; but the patient still is not relieved. Indeed we 
shall find that gout is rheumatism in the small joints; and rheu- 
matism is gout in the muscles and larger joints, though usually 
proceeding from different causes, and occurring at different peri- 
ods of life. Stoll mentions that they are only varieties of the 
same disease. (Rat. Med. Part 3, p. 137, 430.) And Bergius be- 
lieves that they are convertible diseases. The fever continued, 
and a direction of the fluids taking place to the limb, or parts 
affected, swelling ensues, oftentimes resembling that which is 
attendant upon the cruritis or phlegmasia dolens of lying-in wo- 
men; and, like that, affording the patient some release from his 



RHEUMATISMUS VEL MYITIS. 667 

sufferings; for the pain is frequently suspended by the pressure 
upon the nerves of the limb. This disease occurs at those sea- 
sons of the year which are most changeable, as the spring and 
autumn, not so much so in the uniform and steady cold of winter, 
nor in the warm seasons of the year, or in warm climates, with 
the exception of bathing in cold water when heated, or lying on 
the damp ground when the body is perhaps under excitement. 
But in the country it is relatively a disease of frequent occurrence, 
owing to the moisture of the earth, and of the atmosphere, to 
which the inhabitant of the country is exposed. 

Its terminations are, by resolution. Sometimes metastasis, as 
to the head, the lungs, and the heart, especially where the prac- 
tice is feeble. (See Bedingfield, p. 307. ) Abscess sometimes. 
More commonly in a gelatinous affusion; and in deposits of 
earthy matter. In this it differs from many, nay most of the 
phlegmasia^, except it be the gout, to which it is most nearly allied. 
When it ends by resolution, I have known a case where it as- 
sumed the intermittent character, the pain returning at a regular 
hour upon alternate days, but with very little fever. This is called 
by Alibert, the rheumatic form of intermittent. 

DIAGNOSIS. 

It is distinguished from gout by the cause and time of life. The 
ancients knew nothing of rheumatism, as distinct from gout. 
Sydenham was the first who made the discrimination. He had 
experienced gout himself, and saw rheumatism in others. Boer- 
haave too had rheumatism eight months. The best account of it 
is in Van Swieten ? s Com., a book shamefully overlooked. 

Gout usually appears after thirty-five; rheumatism before that 
period of life ; sometimes at five or six years of age. Gout most 
usually arrises from the sanguine and plethoric habit of body and 
free living. 

Rheumatism from cold. In rheumatism, too, the fever is con- 
tinued. In gout, most commonly, it intermits; at least a sensible 
remission is apparent. In gout the stomach is principally affected; 
not so in rheumatism. 

Nephritis is distinguished from it by the peculiar symptoms that 
attend upon the organ diseased, as connected with the stomach, the 
testes, and the round ligaments. Boorhaave, strange to tell, in 



668 LECTURE LVII. 

his own case, committed this error by confounding nephritis and 
lumbago!! Bending the body alone, in nephritis, should decide 
it; whereas in lumbago the body cannot be bent without great suf- 
ffering. 

Hydrargyria is another disease, produced by mercury, that is 
very similar in its symptoms, but differs only in its cause. Indeed 
in the relaxed state of the exciting and sensitive condition of the 
nerves, it is not improbable that cold, in most cases, produces it, 
even though mercury be acting on the system. 

"A course of mercurial medicines," says Heberden, *'has, 
with great reason, been suspected of bringing on something like 
this distemper (chronic rheumatism) in many persons; and it has 
appeared to do so in the same person five or six times; i. e. as often 
as the mercury was repeated." (Heberden, p. 501.) 

Arsenic too produces rheumatism, whether directly or by add- 
ing to the irritability of the system, is not so easily decided. In 
those countries where it is much employed in the treatment of 
fevers, rheumatism is of frequent occurrence. 

PREDISPOSING CAUSES. 

1. Fulness of habit by creating an inflammatory state of the 
system. Sir Clifton Wintringham remarks, that those who have 
undergone amputation of a limb are thereby predisposed to this 
and other inflammatory diseases. G. M. lost a limb. He after- 
wards became plethoric, gout followed; and from this disease he 
suffered severely, notwithstanding the anticipations of the person 
who congratulated him upon the cost of his limb, believing that 
God had great things in store for him, by taking away one of his 
legs. Upon this occasion, he addressed Mr. M. very earnestly. 
Mr. M. replied, " Sir, you really speak so eloquently upon this 
subject, and hold out so many blessings for me, in consequence of 
the loss of my one leg, I am almost induced to lose the other 
also." (Comm. de Morb. Quibusdam, Art. 79.) But to return: 
2. A sanguine temperament. 3. Vigour of early life; i. e. from 
childhood to thirty-five. The young, the vigorous, and the ac- 
tive. Hence, too, we infer its inflammatory character, indepen- 
dently of its symptoms. 4. Intemperance will predispose to it. 
5. A former attack, by which the parts affected are rendered very 
sensible to the exciting cause. 



RHEUMATISMUS VEL MYITIS. 669 

EXCITING CAUSES. 

Cold, heat, or the two alternately applied; violent exercise; 
change of dress; intemperance; wet clothes; cold bathing when 
heated. 

TREATMENT. 

Venesection, general, repeated three or four times. As Dr. 
Gregory used to remark, there is very little danger, as it regards 
the patient's life, but he is in great danger of losing the use of 
his limbs if you do not industriously cut off the flow of blood to 
the inflamed part. Gregory's bleedings were too small; viz. 
about ^xij.; hence he found it necessary to repeat them. Local, 
by leeches; cupping repeated, not regarding the buffy coat, for 
the buffy coat exists in the last stage as well as the first. Thomas 
remarks, that in rheumatism the buff increases as the disease ad- 
vances. So also in intermittents. (p. 157.) Dr. Gregory makes 
the same remarks. Even after one hundred and seventy ounces 
have been drawn, the disease has, in some cases, been unsubdued. 
This treatment was therefore condemned as erroneous by Dr. 
John Fothergill, and by Dr. Haygarth, who then prescribed the 
bark! Fordyce, too, came into their views. (See Thomas, p. 186. 
See also Clin. Hist, of Diseases, Edin. Journal, Vol. 1, p. 482.) 

Saline purges — A course of James' powders. Sudorifics — 
Warm bath; fomentations; sinapisms, moxa. Blisters — Ointment 
of tartarized antimony. Liniments — volatile; camphor, dissolved 
in oil, or the volatile liniment, preferred by Dr. Good to the spi- 
rituous liniment, which he supposes to dry the skin too much ; 
which heats and stimulates without exciting moisture; a waistcoat 
of coarse, brown sheething-paper produces a diaphoresis, and ex- 
cites by the tar with which it is so largely impregnated; oiled 
silk. Diuretics — Nitrate of potash. Dr. Brocklesby's great 
remedy was nitre Dr. Kuhn's also. It was combined with the 
tartrite of antimony. Digitalis has also been by some recom- 
mended on account of its diuretic properties. 

Anodynes are very proper after the inflammatory state has 

been subdued by depletion; in that case, Dover's powders may 

be very beneficially prescribed. It was in this disease that Dr. 

Dover first introduced this valuable combination of opium, ipecac- 

57* 



670 LECTURE LVII. 

uanha and the sulph. of potash. He became celebrated in early 
life as a captain of one of the privateers in Queen Anne's time, 
that sailed round the world. In the last of his life he distinguished 
himself by the introduction of this powder; and by another prac- 
tice he introduced, of giving crude quicksilver — he took it 
himself in large quantities, and became so attached to it that he 
said, if he could afford it, he would swallow a pound of quicksil- 
ver daily — the facetious Dr. Dover, as Fuller calls him. Garth- 
shore and Sir John Pringle as well as most practical writers, con- 
cur in the approval of this sudorific anodyne, which preserves a 
pervious state of the skin, at the same time that it allays the suf- 
ferings of the patient — It should be renewed every three or four 
hours, until sweating is produced — renew it in twelve or twenty- 
four hours to continue the sweat. Rhododendron chrysanthemum 
of Linnseus, also once much in use, both in gout and rheumatism — 
a native of the snowy Alps and mountains of Siberia — in Russia 
also much employed, says Dr. Guthrie. (Med. Comm. vol. 5, p. 
434.) Three or four doses generally giving relief. (See also Pear- 
son's Mat. Med. Home's Clin. Exp. ) Another remedy that has 
come into use in acute rheumatism, is the Peruvian bark. Dr. Hay- 
garth, Dr. Fordyce, and Dr. Duncan, as well as others, viz: Sir 
Geo. Baker, Dr. Heberden, Dr. Saunders, Dr. Willen, Sir Lucas 
Pepys, Dr. Lettsom, Dr. Aikin, and Granger, are the advocates of 
this practice. (See Med. and Surg. Remarks.) Dr. Haygarth intro- 
duced it asearlyas!772. In the hands of others it hasnotbeen pre- 
scribed with equal success — on the contrary, with decidedly inju- 
rious consequences. Dr. Cullen had reason to think it injurious. 
Dr. Haygarth was so convinced of its superior efficacy, that he 
thought the bark did not cure an ague so quickly and so success- 
fully as it does acute rheumatism!! Dr. Gregory disapproves of 
it in the first stage — in the greater proportion of the cases it did 
no good. He observes, it is well to keep it in view, especially in 
cases where you fail to effect a diaphoresis; this last is questiona- 
ble practice. Bedingfield observes that it is generally injurious 
in rheumatism. Thomas uses it but in combination with nitre. 
I have seen it prescribed by Dr. Duncan, in the Infirmary of 
Edinburgh, in several cases, with the most favourable results, 
while in others, with an aggravation of the disease, altogether 
depending on the stage of the disease and the habit of body in 
which it was administered. It is the want of attention to these 



RHEUMATISMUS VEL MYITIS. 671 

particularly, and the want of discrimination on the part of the 
prescriber, that has led to these different and opposite results that 
have been noticed by practical writers. When the disease is 
attended with the symptoms of active inflammation and general 
excitement, the bark as well as other stimuli, must be injurious. 
But there are cases wherein local inflammatory symptoms may 
be continued after the general excitement is taken off, that is, par- 
tial excitement continues. The effect of increased sensibility of 
the part, attended with a small pulse, cool or cold extremities, 
and the general powers of the system greatly impaired and re- 
duced by the depletion the patient has undergone. Thus we often 
see a headache, a sore throat, an inflamed eye, or other local affec- 
tion, are sometimes thus continued, that is, by the stimulus of re- 
laxation, as Mr. Hunter calls it; in other words, irritability or 
susceptibility, which is only relieved by tonics and stimulants 
that shall distribute that excitement throughout the system, and 
which at the same time shall diminish the sensibility of the part 
affected; so of rheumatism. There are cases where stimuli are 
especially useful in this way ; and in like manner, there are cases 
where the sensibility of frame is such that even the whole arterial 
system shall partake of it, and a degree of fever be produced that 
as in typhus, hectic, scarlatina, and other fevers, is only to be 
counteracted by stimuli and tonics. In such cases the bark may 
diminish both pain and fever, by imparting tone to the system, 
and thereby lessening sensibility which is frequently the accom- 
paniment of weakness. In cases of this nature, however, much 
discernment and practical observation are required to know when 
the depletion is to be persisted in or tonics and stimuli are to be 
administered. 

The diet should be the strictest abstinence during the synochal 
stage of rheumatism. No animal food in any shape — on the con- 
trary, a cool, spare diet; milk whey, buttermilk, ripe fruits, gruel, 
panada, rice, &c. I have known the obstinacy of patients and 
their friends, in this disease, by the use of animal food, to render 
all that had been done of no avail, by the excitement being re- 
newed by the use of animal food. Diluents — mineral waters. 
Regimen — do not load the patient with great quantities of cloth- 
ing, or bedding. Flannel or cotton next the skin are assuredly 
necessary and proper; but great care to avoid abuse as to their 
quantity. 



672 LECTURE LVII. 

We now proceed to notice that form of rheumatism which is 
called chronic, the arthrodynia of Dr. Cullen. For the most 
part, as already observed, this is usually the consequence of pre- 
ceding attacks of the acute or inflammatory rheumatism; and is 
continued as the effect of great sensibility of the part, and of the 
whole system. In some cases the secretions are checked, accom- 
panied with a slight degree of fever. Aged persons thus are fre- 
quently affected by pain connected with some febrile symptoms 
induced by a constriction of the surface, or perhaps by debility 
in the extreme vessel. Not unfrequently, too, they are the effect 
of local injuries, as violent exertions, falls, strains, or bruises of 
the muscles or joints, to which the aged are particularly exposed. 
In those cases, mild evacuations by the bowels and the use of 
some diaphoretics will be at first proper; but as soon as fever is 
altogether removed, as in the last stage of acute rheumatism, 
stimuli are called for, especially such as are calculated to preserve 
an open state of the surface of the body. The Peruvian bark is 
had recourse to by some, bitters by others; chalybeates, in the 
form of chalybeate waters, or iron in substance; given in the 
tinct. volatile 3ii« ter in die in milk, decoction of the woods, with 
camphor. J$. guiac 3vj., camphor 3l, opii. 3ij., tart. emet. 3i. 
M. divide in pill 120 — two to be given three times a day. Tur- 
pentine in form of the oil 3i- — ^i. of honey, a teaspoonful occa- 
sionally. Local stimulants — plasters, the emp. calidum, pix 
burgund.,tart. emet. ointment, the Hungarian plaster. Liniments 
— soap lin. with aq. ammon. aa. §ij., turpentine, essence of mus- 
tard, stramonium ointment, spirituous baths, hot baths — 106° 
Fahrenheit — friction with flesh brush, flannel. This was con- 
stantly the practice of the Greeks and Romans; the Chinese, too, 
in health, to prevent disease. The Emperor Augustus, it is said, 
was so completely curried that his skin exhibited the effects of 
the instrument. Flannel shirts,* bandages, rollers, knee cap. 
(See Balfour on bandages in rheumatism. Med. Repertory, vol. 
6. p. 19.) A slight mercurial action in the system is recom- 
mended by Bedingfield, by giving calomel £i. twice a week. 
The dracontium foetidum, or the skunk cabbage, is advised by 
Dr. Thatcher, in his medical practice; of the dried root he ad- 



* A flannel shirt, Dr. Gregory used to tell us, was worth half a dozen of any 
other remedies in this disease. 



RHEUM ATISMTJS VEL MYITIS. 673 

ministers xx. or xxx. grains, three or four times a day, or an in- 
fusion of it. Phytolacca decandra, or poke weed, has been re- 
commended, in the form of an extract from the leaves, or of a 
tincture of the leaves. Tinct. colchicum is also advised. 

The diet should be generous, such as wine-whey, porter, ani- 
mal food. Condiments, as mustard-seed, horse-radish, cayenne, 
&c. 

REGIMEN. 

Let the dress be flannel, frequently changed; exercise, espe- 
cially a journey. If confined to a chamber, the dumb bell, that 
is, a mass of metal with a rope fastened to it and passing it over a 
pulley, pulling it up and down, as in ringing a bell. 



674 



LECTURE LVIII 



GOUT, OR ARTHRITIS. 



We now come that disease of fashionable life, the gout, or as it 
is usually denominated in medical language, podagra, a term de- 
rived from and compounded of two Greek words, rtovs, the foot, 
aud apya, a seizure, denoting the foot as the chief seat of its 
attack. It was with much more propriety, called by the ancients, 
arthritis, which signifies inflammation of any joint; a term which 
I like much better, and have adopted. The ancients called all 
kinds of pain in the joints or the external parts, by the common 
name of arthritis; the word rheumatism was not then known. 
The French, in the 17th century, gave the name of rheumatism 
to the pains affecting the muscles of the neck, shoulders, chest, 
and limbs; but those affecting the joints themselves, they called 
arthritis. Sydenham drew the best description of gout; he him- 
self being a sufferer from it. Cullen has copied him. The an- 
cients, under the general term of arthritis, embraced a great 
variety of names denoting the joints and parts more particularly 
affected. Thus they denominated it when seated in the feet, po- 
dagra; hands, cheiragra; elbows, pechyagra; knee, gonagra; jaws 
or teeth, dentagra; joints of the clavicles, cleisagra; shoulders, 
omagra; spine, rachisagra; large tendons, tenontagra. The 
English word gout, is of French origin, from the term goutte, a 
drop, because it was at first supposed that a peculiar humour was 
deposited or dropped upon the part affected, and that gradually, 
or guttatim. It was first used by Rudolphus, a Dominican of the 
thirteenth century. We shall make use of the term arthritis, as 
not designating any particular joint, at the same time that it will 



gout. 675 

direct our attention to the whole system, instead of a particular 
part, as the term podagra imports. This disease is one of so fre- 
quent occurrence, and is attended with so many formidable dis- 
eases as its accompaniments and its consequences, that it in a par- 
ticular manner claims your attention. I call it a disease of 
fashionable life; that is, it is connected with ease, indolence, lux- 
ury, and those habits of intemperance, both in eating and drink- 
ing, which we find in the higher conditions of society; indeed 
the very first subject of this disease, of which we have any 
record, was a king. We are told in the 15th chapter and 23d 
verse of the first book of Kings, that Asa, king of Judah, in his old 
age, was diseased in his feet; and I believe most of the commen- 
tators concur in supposing his disease to be the one now under 
consideration, for there are few other complaints to which the 
feet are so liable, in advanced life, as the gout or rheumatism, or 
perhaps dropsy, one of the consequences of those inflammatory 
affections. It appears, too, that Asa was very severely attacked, 
for it proved fatal to him. In the second book of Chronicles, 
chap. 16, and the 12th verse, it is again stated of the same king, 
Asa, that in the thirty-ninth year of his reign, he was diseased in 
his feet until his disease was exceeding great, yet in his disease he 
sought not to the Lord, but to the physicians. The next verse 
tells you that it proved fatal to him; that he slept with his fathers 
in the forty-first year of his reign, that is two years after his 
attack. They certainly at that day did not know much of the 
lancet. Hippocrates, too, speaks of it as a disease familiarly 
known; he considers the cause of it to be a mixture of the bile 
and the phlegm, and that these, put in motion, are deposited in 
the joints — no unnatural idea, seeing that the subjects of it are 
generally full habited, and the secretions copious, bilious as well 
as others. Galen also gives a still more minute account of it, 
calling it a defluxion in the part affected. Aetius also speaks of 
it. So that we have reason to infer that ever since eating and 
drinking have been in fashion, gout has been in the train of ills 
that have followed excess. 

Dr. Cullen thus defines the gout: "Morbus hereditarius, oriens 
sine causa externe evidente, sed praeunte plerumque ventriculi 
affectione insolita ; pyrexia ; dolor ad articulum et plerumque 
pedis pollici, certe pedum et manuum juncturis potissimum infes- 
tus; per intervalle revertens; et saepe cum ventriculi vel aliarum 



676 LECTURE LVIII. 

internarum partium affectionibus alternans." I believe it is not 
correct that gout is an hereditary disease, essentially so, allowing 
even that the predisposition is hereditary; for it is in some cases 
doubtless engendered in the descendant, whose parents had not 
the least pretensions to this disease; besides it sometimes appears 
after a manifest exciting cause, as local injury. Dr. Stoll, of Vi- 
enna, I believe, first divided it into hereditary and acquired gout; 
you recollect I told you yesterday he considered gout and rheu- 
matism the same disease. For my own part, as far as I have seen 
the disease, I only consider gout to be hereditary as far as a san- 
guine temperament, vigorous constitution of body, fortune, manner 
of life, luxurious living, habits of intemperance, a fullw ine cellar 
and indolence are hereditary. So far, gout is hereditary, the pre- 
disposing causes being so; but the predisposition exciting the dis- 
ease does not necessarily follow: the disease itself must be created, 
must be earned by the descendant, the usual exciting causes must 
be applied, it is not an exclusive patrimony. But let us take a 
view of the facts upon this subject, as they appear at the bed-side. 
This disease is attended with a synochal or inflammatory fever, 
with symptoms of inflammation in the part or parts affected, and 
that whether the disease occurs in early or advanced life. 

1. This disease usually occurs after the thirty-fifth year; from 
that to fifty. Rheumatism, as we have seen, generally appears 
between puberty and thirty-five, in the greatest vigour of life — 
gout after that period — so that we may say, where rheumatism 
ends, gout begins. I told you that there are cases of rheumatism 
in early childhood ; so there are exceptions with regard to gout; 
I have known it as early as sixteen. Dr. Heberden never saw a 
case before thirty-five. (Commentarii de Morbis, p. 33.) In such 
cases it is induced by early dissipation; in other words, premature 
old age. The celebrated John Randolph, of Virginia, was an ex- 
ample of the early appearance of this disease. He was a lad of very 
extraordinary talents; his society was courted^ even when at Col- 
lege ; not merely from his parents' importance, but his own pre- 
cocious merit. He thence acquired the habits of a man, and at the 
table kept pace with his elders in passing the bottle and other 
luxuries, at the same time that he indulged in late hours. The 
consequence of this inordinate and premature excitement was a 
fit of the gout. It is also to be observed that he did not take the 
usual exercise and amusements of boys, but confined himself to 



gout. 677 

his chamber, and general reading, of which he was particularly 
fond. I have seen another young man, at about twenty-four, af- 
fected with this disease, the effect of intemperance, both in eating 
and drinking. But for the most part this disease takes place in 
the downhill of life, when the vigour of the system is in some 
degree giving way; when the arterial debility, the venous pletho- 
ra, begins to exhibit itself, say after forty — but according to the 
mode of life, as it regards temperance and exercise, it appears 
later or earlier in life. Sir Isaac Newton had his first fit of the 
gout about eighty, and a second in his eighty-fourth year. (See 
Thompson's History of the Royal Society, p. 2S4.) He also had 
a stone in his bladder, which destroyed him soon after eighty- 
four. Dr. Franklin, too, had both stone and gout, which are not 
unfrequently companions, being both connected with a full habit. 
2. Gout also generally attacks the plethoric habit of body — 
those who are in habits of great intemperance, both in eating and 
drinking; those who lead lives of great inactivity and indulgence, 
all of which are favourable to such fulness of the system. Garth, 
who was a physician as well as poet, well remarks of the causes 
of gout and other chronic diseases, 

" Thou well canst boast thy numerous pedigree, 
Begot by sloth, maintained by luxury." 

On this last account, sedentary and literary characters are fre- 
quently the subjects of this disease. Milton fell a victim to gout 
in his sixty-sixth year. (See Rees's Encyclopedia. See also Gar- 
nett's Leet. on Gout. p. 257.) Hence, too, it is the effect of the 
excessive use of spirituous and fermented liquors. On the same 
account it is considered as produced by the free use of animal 
food, and of the condiments of the table, which excite both the 
appetite and the digestive powers, and thereby create this inordi- 
nate fulness of the habit. 

It is from the same cause we meet with this disease most 
usually among the wealthy, who can afford those luxuries, and that 
ease and indulgence we have spoken of; for it is not usually to 
be found among the poor and the industrious portion of the com- 
munity. Plethora of purse, and plethora of body are usually 
associated in the production of gout ; while poverty and labour 
prove both its preventive and cure. Hoffman has justly remarked 
that many have lost their gout with their fortunes. Analogous to 
the effects produced by starvation, upon the patients of Tippoo 
58 



678 LECTURE LVIII. 

Saib, before referred to. Van Swieten relates an anecdote of a fat 
priest who enjoyed a good living, and had been a constant sufferer 
from gout. He was captured by the pirates of Barbary and obliged 
to work two years in the gallies; but he was cured of his gout, 
and lived free from it many years afterwards. This view of the 
subject, too, explains another fact, that persons who do not have 
their regular fits of gout, have some other disease connected with 
and arising from fulness of habit. Dr. John Gregory was found 
dead in his bed, probably from apoplexy. Dr. John Gregory died 
at the age of forty-nine; born June 3, 1724, died Feb. 9, 1773. 
But let us not, with some physicians, call it gout in the brain; 
we may just as well call hemorrhoids or an abscess or fistula in 
ano, gout in the anus, because fulness of the blood-vessels gives 
rise to these diseases. He had had no fit for the three years pre- 
ceding his death ; his mother, also, from whom he inherited his 
sanguine temperament, and predisposition to diseases of an inflam- 
matory character, also died suddenly in, 1770, while sitting at 
table. Dr. Cullen observed that he had known about twenty 
persons die suddenly, more than half of whom were of gouty 
habits. Others again of such temperament and fulness of habit, 
instead of apoplexy, suffer affections of the lungs, such as asthma, 
or they are attacked with hepatitis. 

In other cases, this plethora relieves itself by eruptions, ery- 
sipelas, or perhaps abscesses and ulcers — so with pampered horses 
in the spring. Indeed the fit of gout itself is sometimes an- 
nounced by eruptions, especially about the head, or upon the 
lower extremities. G. M. always noticed the eruptions on the 
head, and the separation of the cuticle, in the form of dandruff, as 
the forerunners of his paroxysm of gout. 



SYMPTOMS OF GOUT. 

Besides the symptom last mentioned, it may be remarked as 
premonitory of gout, that previous to an attack, " both body and 
mind are oppressed," denoting the fulness of the system. It 
comes on with the ordinary symptoms of pyrexia; affecting, 
more or less, the whole system, the head, the stomach; and some- 
times it comes on with inflammatory symptoms, affecting a par- 
ticular part of the body, unconnected with the usual seat of the 
disease. General M — n, upon one occasion was attacked first 



GOUT. 



679 



with ophthalmia; but instantly, by the use of the pediluvium, 
the eye was relieved, and the foot swelled. The same thing took 
place with M. who had an inflammation of both eyes, which were 
relieved by the inflammation of the great toe. (See Johnson on 
Gout, p. 7.) 

Van Sweiten relates a case of pleurisy, which, on the fourth 
day, was instantly relieved by the coming on of gout. Madness 
is relieved in a similar manner by phthisis and the itch, and by 
gout. (p. S.) Accident, too, sometimes decides the part attacked. 
A gentleman was subject to the gout, affecting the foot and great 
toe; but upon a particular occasion, owing to the accident of his 
horse falling with him, he injured his knee. His knee after- 
wards, for some time, became the seat of his disease; but within 
a short time before his death the current took a new direction to 
his brain, producing apoplectic convulsions. He has since died 
of this disease ; and, as frequently happens to apoplectics, he was 
seized in his privy, where he was found in a state of insensibility. 
Sometimes gout appears in the form of rheumatism, in its first 
attack; but ultimately fastens on the great toe, the ankle, the 
knee, shoulder, elbow, wrist, or joints of the fingers. Most usu- 
ally, however, it affects parts previously the seat of the disease. 
In some instances it affects one part, and leaves it for another. 
The symptoms, too, are most troublesome at night, and when the 
sufferer is warm and under the influence of the nocturnal exacer- 
bation in bed. During the day he is comparatively comfortable. 
Pulse frequent and hard, as in the phlegmasia^ in general. Tongue 
dry, clammy and furred, with thirst. Respiration hurried. Skin 
dry with great heat, and burning in the hands and soles of the 
feet. The usual moisture of the feet disappears, but at the end of 
the fit this discharge is restored, and the skin becomes soft. The 
urine pale, and at first diminished in quantity ; but becomes high 
coloured as the disease advances; and after the fit it becomes 
muddy, and deposites large quantities of uric acid like vermilion, 
and attaching itself to the sides of the pot. By this appearance, 
this brickdust sediment, they know the fit has terminated, or is 
at its crisis. The belly, too, is costive. In some cases a more 
abundant discharge of foeces takes place a day or two before the 
fit, and the foeces, too, are more than usually foetid. Is this the 
effect of the impaired state of the digestion, which usually pre- 
cedes the fit, in which case the fermentative process predomi- 



680 LECTURE LVIII. 

nates, and the putrefaction of course, in the lower bowels? Pro- 
bably this is the true solution of the fact. 

Is this owing to the checked state of the excretions by the skin 
in the commencement of the disease, and thereby impairing the 
quantity of the secretions by the febrile state induced ? As in 
the more offensive discharges of women about to be, or rather 
when they are first attacked with phlegmasia dolens, as observed 
by Denman : — as we observed yesterday, was the case in the 
changes produced by fever upon the lochia in the forming stage 
of phlegmasia dolens. 

Is this quickened action of the intestines the effect of the derange- 
ment in the digestive organs that usually ushers in a fit of gout? 
or is it owing to the general excitement of the whole system,, 
quickening that of the intestinal canal ? or is it owing to the mor- 
bid appetite in the commencement of febrile diseases that induces 
the person so affected to take in more food, which thus increases 
the peristaltic motion of the intestinal canal ? When the fit has 
thus commenced, if active means be not employed, this febrile 
state of body and inflammation of the part will continue for many 
days and sometimes weeks \ accordingly some of my friends who 
leave the disease altogether to nature, and decline all medical pre- 
scription, aware of the length of confinement, prepare themselves 
and their apartment, make ready their flannels and other articles 
of dress as much so, and with as much solicitude as any lying-in 
woman. The part affected soon begins to swell, attended with 
great itching, throbbing pain, which at night, when the excite- 
ment of the system is increased, becomes excessively painful. 
Sydenham compares the pain of the foot to the sensation occa- 
sioned by a dislocated bone; and again to the feeling that would 
be excited by a stream of hot water upon the parts affected. 
Some compare it to the gnawing of a dog, the pressure of a vice, 
or the pain of the actual cautery; this probably is not far from 
the truth, judging from the anecdote I have heard of a man sub- 
ject to gout. This man falling asleep, barefooted, before a large 
fire, the fire fell, and a large coal found its way to his foot — half 
awake and half asleep, he cried out, there's that d — d gout again ! 
He at length awoke, when he found a large coal frying his great 
toe. The sensation of the two evils was probably the same. The 
ordinary mode of treatment pursued, too, is calculated to increase 
the flame. I refer to the practice of wrapping up the limb in 



GOUT. 681 

flannel and cotton, which by the accumulation of heat, cannot fail 
to aggravate the disease. At the same time they make use of 
wine and other stimulants for the purpose of keeping it there, as 
the knowing ones express themselves. They are right in this to 
a certain degree; for if they do not deplete the system, they may 
certainly expect it to appear in some other part of the body, and 
perhaps a more dangerous part too, when the disease retires from 
the part first affected, especially if they may have been inclined 
to affections of the stomach, the lungs, or the head, analogous to 
what we have seen in other inflammations. With some, too, it 
is the practice to use cold applications, to immerse the foot in cold 
water — the consequences just noticed, may now be expected; I 
mean the transfer of the inflammation to some other irritable or- 
gan. Dr. Good, too, I perceive, has adopted this cold water 
system, as applied to the feet upon the coming on of gout ! ! 

In urethritis, make use of lead, and a swelled testicle follows; 
repel the eruption from the surface in small pox, or measles, ente- 
ritis, gastritis, or pneumonia, or tetanus succeeds. In like manner 
drive away the inflammation of the feet, you perhaps produce 
gastritis or phrenitis. In the regular fit of gout the part affected 
becomes swelled and inflamed, succeeded by desquamation of the 
cuticle — an oedema of the lower extremities, by effusion into the 
cellular membrane, and sometimes by earthy deposites in the part 
affected, which are at first fluid, but afterwards the thinner fluids 
being absorbed,, the earthy matter or chalk remains behind, 
producing very considerable enlargement of the joints. So in 
like manner, it affects the wrists and fingers as well as the toes, 
and sometimes between the cutis and cuticle. See Moore on 
gouty concretions or chalkstones. (Med. and Chir. Trans, vol. 1. 
p. 112.) Mr. Watson (see Med. Comm. vol. 1. art. 3.) relates 
the case of a man who, when he pla}^ed at cards, was in the habit 
of scoring his game with his knuckles. See also Parkinson on the 
nature and cure of gout. The celebrated Horace Walpole had 
gout at twenty-five — not hereditary in his case, for his father 
drank ale and had no gout. He was an ale, not a wine bibber — 
it affected his hands and feet; chalky concretions were discharged 
once or twice a year. He facetiously observed to a friend, he 
believed he must set up an inn, for he could chalk up a score with 
more ease than any man in England. In some instances these 
deposits on the parts are followed by destruction of the capsular 
58* 



682 LECTURE LVIII. 

ligaments and cartilages of the joints — ulcers and mortification 
follow; but most usually it ends in resolution by the natural 
evacuations of the system, at the same time, that by abstinence, 
(the consequence of the loss of appetite,) the supply of the blood- 
vessels is fortunately cut off. Sometimes, too, the anasarca which 
follows, especially in feeble old age, is rendered permanent from 
loss of tone in the blood-vessels and absorbents, although in the 
first instance, it was the effect of effusion from increased action of 
the arterial and exhalent vessels. Ascites has also, in some cases, 
been the consequence of gout in very full habits, and in advanced 
life, especially if evacuations be not early attended to, before effu- 
sion has taken place. In some cases, too, from a diseased liver, 
the effect of the same fulness of system. 

Writers usually divide gout into a number of species. Mus- 
grave makes almost as many species of gout, as there are diseases 
to be associated with it; he has his regular and anomalous, fixed 
and wandering, manifest and obscure, febrile and that which is 
unconnected with fever. I know but one — for at the bed-side I 
see but one. I grant, as far as the general state of the constitution 
is concerned, that it is very much of a Proteus, exhibiting itself 
in various shapes, sometimes affecting one part of the system, at 
others a different: in one habit of body, we know it attacks the 
foot, in another, the stomach, in a third, the lungs, in a fourth, 
the brain ; but these can only be considered as varieties, not spe- 
cies. Such Sauvages considered them. But Dr. Cullen divides 
gout into four species. In a note upon this subject, in his Noso- 
logy, he questions his own correctness in making the distinctions 
he has introduced. "Me ubique accuratum fore non spondeo." 
(p. 127, vol. ii.) His first he denominates regular gout, which is 
attended with a violent inflammation of the joints, continuing se- 
veral days, and terminating in swelling, itching, desquamation of 
the part affected, and sometimes a permanent anasarca. 2d. 
Atonic gout, characterized by debility of the stomach, or of some 
other internal part, and is either without the expected or usual 
inflammation of the joints, or is attended with slight fuga- 
cious pains or intimations in them ; but is, more especially, 
attended with dyspepsia or other symptoms of debility, and often- 
times the irritations of the joints, and the disturbance of the di- 
gestive organs, alternating with each other. In some instances 
this atonic gout shows itself, not in the feet, nor in the stomach, 



gout. 683 

but in the brain. The late Mr. R., of this city, was subject to 
gout ; but instead of his regular fits returning in the extremities, 
the apoplexy was his disease, and which proved fatal to him, not- 
withstanding the use of the lancet : whether he was bled freely 
or not, I know not, or whether a rupture of the vessels of the 
brain may have taken place is doubtful. The third species of Dr. 
Cullen is his retrograde gout, which first appears in the joints, 
and then, by metastasis, suddenly disappears, followed by affec- 
tions of the stomach, or some other internal parts: this, however, 
is certainly but a modification of the atonic, for this is its charac- 
ter, that instead of the extremities, the fulness of habit and ex- 
citement fall upon some other part. His fourth he denominates 
wandering gout, aberrans, i. e. affecting some internal part, and is 
in some cases accompanied with some affection of the joints — in 
others, not; that is, the patient experiences some irritation from 
the fulness of his system, but which he has not vigour enough in 
his small vessels to direct to his extremities, but which confines 
its effects to the larger vessels, and those parts less distant from 
the heart. Here then Dr. Cullen makes another distinction with- 
out a real difference. This very enumeration bespeaks them to be 
all mere varieties of the same affection of the general system, in- 
fluenced by temperament or constitution. In the sanguine tem- 
perament we see regular gout; in the nervous or melancholic, we 
find the stomach, and not the extremities, the seat of irritation, 
with all the symptoms of dyspepsia, visceral obstructions, and 
hypochondriasis connected with it; and in the advanced period 
of life, when venous plethora predominates, it affects the brain, or 
perhaps fortunately vents itself by hemorrhoidal discharges ; but 
let us not commit the error of denominating phrenitis or hemor- 
rhoids, gout. Gout is generally said to arise from a peculiar con- 
dition of the circulating fluids. This I believe to be true ; but I 
also believe that this condition does not consist so much in any 
peculiar vice, as in the quantity and viscidity of those fluids. I 
grant the quality becomes changed; but this change I believe to 
be the consequence of the quantity, and the want of due dis- 
charges, by the natural outlets of the system. Let us then be 
careful not to mistake the effect for the cause. But, say they, we 
observe a peculiar matter deposited in the joints. Granted; the 
chemists, too, have analysed it. Mr. Woollaston tells you it is 
made up of the lithic acid, in union with soda or with lime, con- 



684 LECTURE LVIII. 

stituting the lithiate of soda or the lithiate of lime. Dr. Pearson, 
in the same year, finding the same acid in urinary concretions, 
having examined upwards of three hundred calculi, proposed 
thence to call it the uric acid; this salt, therefore, now receives 
the appellation of the urate of soda or the urate of lime. But 
remember all urinary concretions are not made up of these two 
ingredients only; on the contrary, you get various combinations, 
as appears by Mr. Woollaston's analysis, and others, viz : uric 
acid, urate of ammonia, phosphate of lime, phosphate of ammonia 
and magnesia, oxalate of lime or mulberry calculus, besides silex 
and animal matter. But by consulting Wilson on Gravel and 
Dyspepsia, you will learn that the skin, the stomach, the intes- 
tines, even the salivary glands and the lungs, as well as the kid- 
neys, pour out more or less of the lithic or uric acid. The pre- 
sence of this acid may be readily tested by litmus paper turning 
red. We also see the same combination that constitutes the gouty 
concretions, deposited in various parts of the body, in the brain, 
even loading the pineal gland. In the urinary discharge, in 
health and in disease, after pleurisy, rheumatism, gout, and vari- 
ous other diseases of the class of phlegmasia^, and occurring in the 
full habit of body, we see the lateritious sediment, the brick dust, 
vermilion-like matter lining the urinal. Are not these all ascriba- 
ble to a plethoric state of body, and an inflammatory diathesis, 
chiefly occurring in the sanguine temperament? In other words, 
a redundant state of the fluids occasioning such deposits — some 
more than others; some thereby more predisposed to these vari- 
ous inflammatory affections than others; and does not this san- 
guine plethoric habit of body account for the hereditary character 
of the disease; the hereditrry affections of the stomach, liver, 
lungs, &c; the hereditary gravel and stone, so frequently the 
associate of gout ? In a word, that an overloaded state of the 
blood-vessels, influenced by temperament and mode of life, creates 
these various affections denominated arthritic. 



685 



LECTURE LIX 



CAUSES OF GOUT. 



The predisposing causes of gout are — 1st. The sanguine tem- 
perament. Hence it appears more in some families than others. 
2d. A plethoric habit of body. Hence you find full feeding and 
wine drinking so intimately connected with the production of 
this disease. Hence, too, it is more usually the disease of males 
than females. It is indeed proverbial, that women and eunuchs 
are rarely affected by gout. Women escape, owing to the tem- 
perate mode of life which they usually observe; and when 
women are the subjects of gout it is usually after the natural 
cessation of the menses: if before, they usually acquire it by 
their mode of living; but even after the natural cessation of the 
menses has taken place, it rarely appears without the aid of the 
bottle, and too free use of the more potent stimuli of the table. 
Hippocratus, even in his day, observes, that women seldom have 
the gout, and never before the disappearance of the catamenia; 
but among the Roman ladies we find it a disease of frequent oc- 
currence; and which Seneca ascribes to their luxurious living, 
and the debaucheries in which they indulged without control. 
(95th Epistle.) Hence, too, it happens, that the full habits which 
are liable to gout, when the vigour of the small vessels diminish, 
are also apt to end in apoplexy or palsy, or in diseases of the 
liver, or in dropsical affections upon the chest or in the abdomen, 
or sternalgia, and other affections of the heart and larger vessels; 
sometimes creating deposits of the earthy materials of the blood 
in the valves of the heart. The ventricles, therefore, fail to 
empty themselves; an enlargement, interruption of the circula- 



686 



LECTURE LIX. 



tion, and serous effusions are the consequences. Hence, too, it 
has sometimes fallen upon the lungs themselves, and destroyed 
the patient by tubercles, and other evidences of inflammation 
of those organs. 

Dr. Cullen and others have concurred in the observation, that 
the Portland powder, (which chiefly consists of bitters; viz. gen- 
tian, at least this is its most active ingredient,) which was cele- 
brated for the prevention of gout; when persisted in for any 
length of time, produced apoplexy, palsy, asthma and dropsy. 
But there is no mystery as to the production of those diseases 
without that auxiliary. Looking at the habits attacked, and the 
causes operating, the mystery vanishes. 

Dr. Darwin, too, ascribes to the hop, and other bitters, made 
use of in beer, what is in part due to the beer itself, in the pro- 
duction of apoplexy and affections of the liver. But not only 
natural fulness of the habit predisposes to this disease, but the 
acquired fulness and excitement occasioned by full living. The 
excessive use of wine, porter, animal food, the condiments of the 
table, predispose to this disease ; and, indeed, of themselves, I 
believe, in some instances, excite it. It is not necessary to de- 
scend from titled parents to get the gout. Some persons, without 
any other patrimony than a sanguine temperament, and a good 
constitution, acquire this disease by their own intemperance, or 
free living. An elderly gentleman in this city, whose predeces- 
sors cannot boast of their coat of arms, but who had never known 
of this disease in the family before, acquired this complaint by 
his mode of living. His first attack took place in advanced life, 
from want of exercise, and the free use, not of wine, but of spi- 
rituous liquors, and of animal food. He had regular paroxysms 
annually, and sometimes semi-annually. It is not, therefore, 
necessarily an hereditary complaint. In some instances, I have 
remarked, it appears early in life; i. e. where early dissipation is 
indulged ; but most usually it occurs at an advanced period of 
life, which proves another predisposing cause of gout, by the debi- 
lity that takes place in the extreme vessels, and the diminished 
excretions, the consequences of that debility. Hence it is that 
debility of various sorts, and especially that of excess — in wine, 
in women, and the indulgence of the passions, is the parent of 
this complaint. Hence the adage — 



CAUSES OF GOUT. 687 

"Bacchus pater, 

Venus mater, 
Et Ira obstetrix arthritidis." 

For in that state of debility, those organs, the usual seat of that 
disease, are most irritable, and inflammation follows. A previous 
attack also, in a peculiar manner, predisposes to a second, by the 
debility induced, as the parts once the seat of sore throat, of 
pleurisy, rheumatism, erysipelas, or other inflammatory diseases. 
So gout is easily renewed by change of weather, of season, or 
other exciting causes. The more variable seasons of the year, 
too, are to be enumerated among the predisposing causes of this 
disease, as the spring and autumn; but, like the rheumatism, it is 
not so frequently a disease of the winter as of spring and fall; 
except when the weather is unusually variable; and in summer it 
is very rarely met with. On the contrary, this is a season of 
perspiration, and of depletion, instead of eating and drinking; 
for in summer the appetite is fortunately impaired, especially for 
animal food; and vegetables and fruits are less exciting to the sys- 
tem than animal food, and at that season constitute the largest pro- 
portion of our aliment. It is also a season of exercise, which 
usually also secures the subject of gout at that season. Our gouty 
gentlemen then usually have recourse to a journey, or they resort 
to our watering places, to Rockaway, Long Branch, and Ballston, 
to dilute their wine by water, and restore themselves after their 
winter's campaign. They go away for health ; but by their mode 
of living, they bring back great pabulum for the disease. 

In like manner many other diseases that appear in the more 
changeable seasons, rarely take place in summer, as most of the 
phlegmesiae; the cutanei, and other diseases, as apoplexy, palsy, 
and other of the neuroses, connected with fulness of the brain, as 
mania and hypochondriasis, but which are frequently ascribed to 
debility, the effect of cold ! ! whereas they proceed from the ple- 
thora attendant on winter, in which our excretions are diminished, 
and our ingesta increased — in which our income exceeds our out- 
goings. Thus it is that we see gout counteracted by the climate. 
In Champaign and Burgundy this disease is scarcely known, yet 
it is well known too that they drink freely of wine, especially 
the lighter wines, and wines too abounding in acidity. This 
effect of a warm climate, probably by its operation upon the ex- 
cretions, especially by the skin, accounts for the prevalence of 



688 LECTURE LIX. 

the disease in one climate, or country, while another is exempt; 
hence the remark of Lucretius, " G-out clogs the feet in Attica; 
the sight fails in Achaia." In like manner, in China,* the 
gout is scarcely known ; while in the variable climate of Great 
Britain it is readily induced by the application of the ordinary 
existing causes. It is frequently said, that persons who are re- 
markable for a plentiful perspiration generally escape the gout 
although they may indulge in an abundance of wine, and the 
other good things of the table. A gentleman in this city, who 
has always, through a long life, fared sumptuously every day, is 
a remarkable instance of this exemption from gout, altogether 
attributable to exercise and a constant current from the surface. 
But again, the inhabitants of the Feroe Islands, who live by fish- 
ing, though they drink no wine, yet in consequence of their alter- 
nate exposure to cold and wet clothing, and their hot drying 
rooms, together with spirituous drink, are the subjects of gout: so 
says Landt, in his description of the Feroe Islands. Here, then, 
is an exception to the general remark, that gout is a disease of the 
rich and the indolent. Here the labouring poor are also the suf- 
ferers from this complaint. 

THE EXCITING CAUSES 
Are, 1. cold, especially combined with moisture. In the case 
of Mr. H. it was thus first induced, having been thus exposed 
four days and nights in an open boat, at the Cape of Good Hope. 
None of his family before him had experienced this disease, yet 
I never saw a more regularly formed disease, or more uniform in 
its returns than in that gentleman. He is now in a warm cli- 
mate, and perhaps enjoys an exemption from his ordinary visi- 
tations. His son states that he has been sensibly benefitted by 
change of climate. 2. A debauch, especially the excessive use of 
wine and ardent spirits. Porter drinking, by loading the vessels, 
and being less stimulant, does not so readily beget gout as wine 
and ardent spirits; on the contrary, it most usually ends in dis- 
eases of the liver, or in the production of dropsy, apoplexy, or 
palsy. It requires the more potent diffusible stimulant of wine, 
and a vigorous state of the system, to carry on an uninterrupted 
stream, the disease, to the feet. Porter and malt liquors in gene- 
ral are more apt to bolt from the course, or rather to halt by the 

* Le Conte, see Good, vol. ii. p. 507. 



CAUSES OF GOUT. 689 

way, filling the larger vessels of the head, the chest, or the vis- 
cera of the belly. Van Swieten accordingly remarks that when 
the people of Holland drank malt liquors, gout was scarcely 
known ; but he adds, that this disease has become very common 
among the Dutchmen since the introduction and more free use of 
wine. Cadogan also observes, that he had been assured by a 
physician who practised above thirty years in Turkey, that from 
the Danube to the Euphrates he had never seen a gouty Turk; 
but the courtiers, it appears, were not as good Mahometans; they 
drank wine, gout was their disease. The same physician, Cado- 
gan, states, that he has been credibly informed that the Gentoos, 
the simplicity of whose fare is proverbial, know not this disease, 
so exclusively does it arise from diet and luxurious living. 3. In- 
digestion, from quantity or quality, is also among the exciting 
causes of gout; hence, bad wine, punch, lemonade, small beer, 
some particular article of diet too much or too little done, are 
sure to be noticed by the bon vivant, as the exciting cause of his 
complaint. It is true that a little thing will light the flame; will 
kindle a fever in this combustible state of body. 4. Violent 
exercise. 5. An injury done to the foot or to the joints, the 
usual seat of the disease, will, in some cases, renew the paroxysm 
by the inflammation induced. The pressure of a tight shoe or a 
boot has been known to induce it; thus too, an injury of the knee 
has made that the seat of attack, when it previously appeared in 

the foot. Mr. C r had the disease ordinarily in the feet, but 

injuring the knee, his disease for some time uniformly fastened 
itself there. In 1816, he took a long journey through the north 
western parts of this state, and escaped his usual attack in that 
and the next succeeding year. He afterwards became the sub- 
ject of apoplexy, and after two or three attacks died suddenly. 

The proximate cause of this disease, agreeably to the facts that 
have been adduced, appears to consist in an active unmixed in- 
flammation of the part or parts affected. To convey my idea of 
the disease, I call it rheumatism in the small joints, and rheuma- 
tism gout in the larger joints and muscles. All the predisposing 
and exciting causes of this disease bespeak its nature. It is not 
then an hereditary disease, except so far as the peculiar tempera- 
ment or constitution, and the mode of life may render it so. In- 
deed, were it an hereditary disease, we should not so frequently 
see it engendered in the individual whose ancestors on both sides 
59 



690 LECTURE LIX. 

have lived to a great age without a symptom of it Another con- 
sequence would be inevitable — females as well as males would be 
its unavoidable subjects — not so is the fact; they have a predispo- 
sition in the sanguine temperament, and a good constitution; but 
let them avoid the usual exciting causes of the table, and take 
regular and daily exercise, they escape the disease. 

TREATMENT. 

The cure of this disease does not consist merely in patience 
and flannel, as recommended by Dr. Cullen and others. True it 
is, they go together, for the more flannel the more patience is cer- 
tainly necessary, to bear the additional sufferings which great 
accumulation of heat produces in the part the seat of inflamma- 
tion. Dr. Thomas, too, has tamely copied Dr. Cullen on this 
subject. Nor shall I recommend the contrary practice of applying 
cold water to the limb the seat of the disease, as was the practice 
of the ancients, and which has lately been received by Dr. King- 
lake and others, and by Dr. Good! Hippocrates, iEtius, and 
Celsus, advise this practice. That they should not have formed 
a correct view of the nature of this disease, is not surprising, as 
they could not have known the nature of the fluids of the sys- 
tem, and the changes induced in the nature of the excretions. 
Besides, gout at that day was a disease of rare occurrence, com- 
pared with its present prevalence, especially since the great dis- 
coveries and improvements which have been made in kitchen 
chemistry, or the science of gastronomy, as the savans of France 
denominate it. To our great surprise, we find the same practice 
recommended by Harvey. He immersed his own feet in cold 
water at the approach of a fit of gout, and fortunately escaped the 
evil consequences of the application, and lived to the age of 
eighty. Van Swieten, too, relates the case of an officer of the in- 
fantry, who rubbed his feet with snow and walked barefooted on 
the snow, in the commencement of the gout, and with success. 
See also Rigby on animal heat. (Med. Obs. vol. 6.) Most of 
those whom I have known to follow this practice, have either 
died of appoplexy, or have become affected by other diseases 
more dangerous in their nature and consequences than the origi- 
nal disease of gout. The late Dr. Joseph Brown, of this city, 
pursued the practice of immersing his feet in cold water, at the 



TREATMENT OF GOUT. 691 

approach of every fit of gout. He is since dead of appoplexy. 
As in the indiscriminate application of cold water in febrile dis- 
eases, a man knows little of the condition of body existing either 
in gout or fever, or of the powers or functions of the system by 
which they are to be removed; who can thus depend exclusively 
upon the application of cold — who, in other words, can consider 
gout and fever as consisting merely in a high temperature of the 
system, or of a particular part? On the contrary, this remedy is 
to be made use of very cautiously, for the reason before assigned, 
lest some other part of the system should become the seat of irri- 
tation, as the brain, the stomach, the lungs, the liver, or the heart. 

By the application of cold to the part, you may relieve the local 
irritation ; but the patient is only relieved to be attacked in a 
more formidable manner. You dam up the fluids in one direction, 
but they overflow in another. Tepid applications are in such 
eases to be preferred, and they certainly afford the same relief 
without the danger to be apprehended from cold. Nor shall I 
recommend to you an exclusive dependence upon the late cele- 
brated remedy which has been received within a few years: 
Ci the Eau Medicinal d' Husson," though it is considered a remedy 
of great value. But I believe, indiscriminately as it has been 
prescribed, it is rather more valuable to the physician than to the 
patient. But as it operates as a cathartic, diuretic, and sudorific, 
it may certainly be useful in slighter attacks of the disease, and 
thus be found a valuable auxiliary in the cure of gout. I have 
already told you, that most physieians consider this medicine to 
be made of the colchicum autumnale; some, again, consider it 
as prepared from the rhododendron chrysanthemum. 

The indication, which appears to me to arise out of the view 
we have taken, will be to divert the action from the part, by di- 
minishing the volume of fluids, and thereby diminishing the 
momentum and activity of the circulation; and by restoring the 
natural excretions of the system. If arising from plethora and 
inflammation, these cannot fail to afford relief. And if they arise 
from any particular morbid material, or vice, of the system, 
we cannot possibly adopt a safer mode of practice than by 
opening the various excretions by which the enemy may find 
an outlet. It will at least lessen the febrile state of body, which 
such irritating material within may create. But my own belief 
is, that gout is a simple inflammatory disease, in the smaller 



692 LECTURE LIX. 

joints, analogous to rheumatism in the larger, only influenced by 
the habit of body in which it occurs, and the causes exciting it. 
But inasmuch as it arises in a particular habit of body, and is 
produced by a different exciting, as well as, in some respects, dif- 
ferent predisposing causes, so it exhibits some peculiarities which 
are not usually found in rheumatism. But in many other respects 
the two diseases are the same. 

Gout arises from internal causes — rheumatism from external. 
The external causes being continually applied, the disease is ac- 
cordingly removed. Not so with rheumatism, which is generally 
the effect of cold. It therefore has not its regular returns, like 
gout. But the same exciting cause; viz. cold, will produce gout 
in one habit of body — rheumatism in the other; and can, there- 
fore, only be distinguished by a reference to their causes, and the 
constitution, time, and modes of life. 

My treatment corresponds with this view. Venesection, 
accordingly stands at the head of the list, as in other diseases of 
inflammation, and should be employed in proportion to the vio- 
lence of the disease, and its duration; but with caution in the last 
stage, as in other inflammatory diseases; taking into view, at the 
same time, the age, habit, and debility of the patient; not forget- 
ting the question of Celsus, " Quae vires sint?" This, I know, 
is a heresy; but we have highly respectable authorities in support 
of this practice. Sydenham, Huxham, Cullen, Musgrave, Dr. 
Robert Hamilton of Lynn, (Eng.) and Dr. Rush, have all recom- 
mended it. Hamilton employed it eighteen years upon himself 
and others, without ever producing any retrocession of the dis- 
ease to other parts of the body. This is the best mode of saving 
the other organs from injury. Nor was Musgrave satisfied with 
general blood-letting. He made use of, and advised cupping, 
scarifying and leeches. These, too, I consider well calculated to 
diminish the local inflammation attendant on this disease. Dr. 
Cullen recommends them also, when the inflammation is uncom- 
monly violent. Do not wait for this violence before you employ 
these means of diminishing inflammatory action, when it has 
commenced. 

2d. Some writers recommend emetics in this disease. In the 
sixth volume of the Lond. Obs. and Enquiries, you will find 
Dr. Small's account of their use, in his own case. He states that 
he employed them with decided effect. Dr. Pye also recommends 



TREATMENT OP GOUT. 693 

them in this disease. Without previous blood-letting, especially 
in persons of full habit, and who are consequently liable to apo- 
plexy, they are certainly dangerous in their operation. And as the 
stomach is the irritable and weak part in gouty habits, I should 
hesitate exceedingly to administer emetics in the manner they 
advise. Occasionally the stomach is in that condition that may 
require the operation of an emetic to cleanse it. In that case, a 
mild emetic may be administered. 

3d. Cathartics are indicated. But as the patient is more or 
less dyspeptic, let them be such as are not very debilitating, espe- 
cially if the patient be advanced in life. Rhubarb and vitriolated 
tartar to the quantity of 3ss. each; or rhubarb, 3i.; magnesia, 3i.; 
and mint-water, §iij, are among the best means to be directed 
with this intention. 

Saline purges are generally too cold and debilitating to the 
stomach, and renders that organ still more irritable, and hence 
may produce spasms of that viscus, called gout in the stomach, 
and which sometimes ends in inflammation. The Cheltenham 
salts, and Cheltenham waters, are considered exceptions to this 
observation. According to Jameson's analysis they consist of 
the sulphate of soda, the sulphate of magnesia, with the carbonate 
of lime and a portion of iron. They are accordingly found not 
to debilitate as the ordinary saline purges, at the same time that 
they are equally useful in removing visceral obstructions, as those 
of the liver. On these accounts they are very much resorted to 
in gouty habits. Sydenham's caution as to the debilitating effects 
of strong purges in this disease is certainly just; but, like the 
satyr in the fable, he blows hot and cold at the same time; for, 
according to his principle you would not give them at all, strong 
or weak; for he tells you that purges in the beginning of the dis- 
ease are injurious, inasmuch as they prevent the matter of gout 
from fixing itself upon the foot; and again, that they are injurious 
in the last stage, after a fit is over, by bringing it back again 
into the feet. Theory, certainly not practice, influences Syden- 
ham on this subject. His observations are, however, just, as it 
regards the effects of very debilitating cathartics. Those I have 
referred to are assuredly beneficial in the commencement of gout. 
Hoffman himself had recourse to a purgative, before or in the 
commencement of the fit of gout, and he tells you with great 
benefit. A late writer, probably Dr. Bateman, (see Rees's Cyclo- 
59* 



694 LECTURE LIX. 

pcedia,) also states that he has known the fit of gout to be pre- 
vented by taking a brisk purgative, viz. fifteen grains of scam- 
mony, when the first symptoms appeared, making a smart coun- 
ter current. Van Swieten is also in favour of cathartics in this 
disease. Dr. Rush is also the advocate of this practice. I have 
frequently also, in the case of the late G. C. of this city, parried 
his fit of gout by means of rhubarb, magnesia, and mint water. 
3d. Attend to the skin; but let it be relaxed by such means as 
will at the same time diminish excitement, viz. by the sp. mind, 
and laud.; by Dover's power; antimonial wine and laudanum, 
aided by tepid drinks; and if the stomach be weak, by herb teas, 
as catnip and mint, or weak wine whey, otherwise great caution 
is necessary in the use of wine. The spirituous steam bath is re- 
commended by Blyborough, in his communication on gout, (see 
Med. and Phys. Journal, vol. xii. p. 62.) It was a few years 
ago introduced into this city, and was employed by Gen. B. In 
his case it was made use of before venesection. It manifestly 
aggravated his sufferings, and produced all the symptoms of ap- 
proaching apoplexy, and which blood-letting alone prevented. 
Another gentleman also made use of it, and with an evident in- 
crease of his disease; but a tepid bath, tepid fomentations, a cot- 
ton poultice, I mean a light covering of carded cotton, or flannel, 
for the purpose of promoting perspiration, and preserving an 
uniform temperature, are doubtless proper; whereas the immense 
loads of clothing, either to the limb or to the whole body, which 
are usually directed, are no less pernicious. 

4th. Some physicians recommend blisters. Dr. Chalmers used 
them in his own case. Dr. Rush also bears testimony to their 
use, and the relief they afford. 

5th. The sufferings of the patient are also to be lessened 
by opium; that is, after evacuations have been made from the 
whole system, otherwise the consequences noticed by Caver- 
hill may be looked for, viz. apoplexy or palsy, especially, he ob- 
serves, in the aged; not so after venesection. Dr. Cullen does not 
appear to be aware of these dangers from opium ; but its effects, 
in diminishing the circulation in the smaller vessels, and in filling 
the larger, are not to be questioned after the experiments of Dr. 
Monro. After blood-letting one of the best forms of administer- 
ing opium; and indeed, generally, when you wish to diminish 
pain and to relax the skin, is in the form of Dover's powder, or 



TREATMENT OF GOUT. 695 

in combination with camphor, or the celebrated drops of Dr. 
Friend, viz. camphorated spirits two parts, laudanum one part, a 
teaspoonful every two or three hours. Dr. Charlton found them 
to be exceedingly friendly in his case. 

6th. The tincture of colchicum has lately been administered 
with great success in this disease; its sensible effects upon the 
stomach, bowels, and skin, as well as its anodyne operation upon 
the nervous system, certainly recommend it to our confidence as 
an auxiliary in the treatment of gout. A strong saturated tinc- 
ture of hops may also be useful in the same manner. 

7th. A connexion existing between gout and nephritis, has 
induced some physicians to recommend alkalis and magnesia, as 
a specific to counteract the uric acid; but they are neither to be 
depended upon, as those urates are deposited as the effects of ful- 
ness and excitement, by the removal of which alone, the cure of 
the disease is to be effected. They are no doubt palliatives in 
gout, by correcting the fermentation attendant on the deranged 
state of the digestive organs; and in nephritic affections they 
doubtless may be, and probably are useful in correcting, and per- 
haps by decomposing the saline materials, the effect of such ple- 
thora. They may in like manner, correct the general lithiasis of 
the system, frequently accompanying the gouty habit of body. 

The diet in the first stage, should be simple and strictly anti- 
phlogistic; toast water, herb teas, soups, vegetables, roasted ap- 
ples, light puddings. The regimen, in the first stage, should 
particularly have reference to the temperature of the room, 
drinks, and baths. Quiet should also be enjoined. Let the 
patient also be directed to abstain from business and company, 
for friends now usually come with their congratulations, forsooth 
that the man is not to die of an apoplexy, and that he has his 
inflammation at the other end of the body; they profess to give 
him joy of his gout; but they materially add to his distress and 
sufferings. It is, I believe, not to be doubted that the gout, like 
some other diseases, wastes its irritation on the extremities that 
would otherwise vent its force upon an internal or a vital organ. 
So far it may be considered as comparatively a salutary disease. 

SECOND STAGE. 

This is evinced not only by manifest general debility, and per- 
haps emaciation, but also by anasarcous swellings; or perhaps, 



696 LECTURE LIX. 

ascites, with diminished urine. Tonics and stimulants, general 
and local, are now indicated at the same time that those means 
are to be preferred which have most effect in restoring the sup- 
pressed excretions. For these purposes — 1. Bitters, viz: the in- 
fusion of columbo; gentian with soda and rhubarb. 2. Iron in 
its various forms of filings with ginger, or extract of gentian, or 
rust with do. or canalla alba, or Ballston waters. This has been 
found like the Cheltenham waters, very beneficial. 3. Diuretics, 
viz: horse-radish, parsley roots, mustard seed, &c; or the diu- 
retic decoction of the seneka snake-root, and juniper berries. 
4. Sudorific stimulants, as tinct. guaiac. simp, or volatile. 5. Lo- 
cal stimulants, bandage and the flannel roller, liniments, turpen- 
tine, &c, except eruptions or ulcers exist, yeast may be required, 
pickled flannels, flour of mustard. 



DIET. 



Gradual return to animal food, wine also — a hair of the same 
dog will be necessary and proper — the condiments of the table, 
too, now are useful, especially mustard, salt, horse-radish, and 
cayenne pepper. 

REGIMEN. 

Exercise in the open air, to the sea-shore, in a carriage at first, 
afterwards on horse-back; friction with the flesh-brush, or the 
hands, not forgetting the spirituous liniments, and Dr. Balfour's 
flannel roller, while the limb is relaxed or swelled, or pits on 
pressure. 

So much for legimate gout. But should the disease suddenly 
disappear from the feet in its commencement, and while the sys- 
tem is under great general excitement, it should invade the 
stomach whether this organ be the seat of irritation from a dys- 
peptic state of it or from a loaded state of the liver, what is now 
to be done? 

I am speaking of the first stage of gout, when it is first display- 
ing itself, and the customary fit of it has been expected. In such 
case the pain in the stomach soon ends in gastritis, and proves 
fatal, unless vigorous treatment be pursued. Venesection is now 



TREATMENT OF GOUT. 697 

necessary, and remember to bleed freely, or your patient will die, 
and you will be charged with killing him; for a small bleeding 
will do him no good, and you will in that case be censured for 
bleeding him at all; therefore, do it as it ought to be done in any 
other of the phlegmasia^; fortunately too it is one of the best anti- 
spasmodics you can prescribe. The bowels should be relieved by 
injections, and opiates may be administered freely, especially the 
Dover's powder. If, however, you have reason to consider the at- 
tack more of a spasmodic than an inflammatory nature, laudanum 
and mint- water will be preferable, and should be administered in 
large quantities. Fomentations to the stomach, viz : with mint and 
brandy, and those applied as hot as the patient can bear them, he 
being free from fever, are also proper in these irritations of that 
organ. Blisters, immersing the feet in warm water, adding spirits 
to the bath, friction with mustard, covering the part with flannel, 
frequently invite excitement there, and, by metastasis, remove the 
irritations of the stomach. Spiced wine, aether, hot toddy, are also 
valuable auxiliaries with this view. As to the effects of gout affect- 
ing the brain, it then assumes a new character, that of apoplexy, 
and is to be treated accordingly. One word upon the preven- 
tives of gout. As the causes of this disease are for the most part 
intemperance and indolence, so the best means of preventing its 
return may be summed up in their immediate antidotes, temper- 
ance and exercise, i. e. temperance in eating and drinking, not 
only as to quantity but quality. Instead of wine, spirits, porter, 
ale, or other fermented liquors, water should become the beve- 
rage of the sufferer from gout; he, at least, should take moderately 
of wine. Remember the anecdote of Marmontel. He had been 
much subject to head-ache and giddiness of head, the common 
consequences of a sedentary life and full feeding; his farrier went 
into his room during one of those attacks, and who appears to 
have known the nature of his disease much better than his physi- 
cian. The farrier was satisfied that Marmontel's complaint pro- 
ceeded from fulness of his vessels, and the viscidity of his blood. 
Marmontel asked John what he should do to relieve them. The 
farrier in return asked Marmontel, who was at his writing-desk, 
Sir, suppose your ink was so thick that it would not flow easily 
from your yen, what would you do? I would add water, says 
Marmontel. Do the same, sir, with your blood. Marmontel took 
the hint, and profited by John's prescription. A patient of mine, 



69S LECTURE LIX. 

who has suffered many severe attacks of the gout, by means of 
dilution, and abstinence from his customary quantity of wine, and 
the occasional use of the elixir proprietatis, keeping his digestive 
organs in good order, has escaped the disease for many years. I 
do not, however, approve of the rigid abstinence enjoined by Ca- 
dogan — this is not necessary; temperance in all things should be 
the motto of the patient liable to gout; but to proceed from one 
extreme to the other is only calculated to relax the body, and fill 
the vessels, and thence, if not to beget gout, it is likely to produce 
some of its associate or vicarious diseases, as apoplexy or palsy; 
for where persons have been long in the habit of using powerful 
stimulants, sudden abstinence is apt to induce dyspepsia, with a 
general irritability of fibre, and greater liability to inflammation 
from cold, &c, and in some cases, venous plethora, showing itself 
in an apoplexy, palsy, or a diseased liver, and dropsy has been 
the consequence of such system of abstinence. Exercise is no 
less necessary to secure the system against that fulness of habit 
and excitement constituting gout. The late Dr. James Gregory 
was an example in whom the gout, though the predisposition was 
hereditary, was banished by abstinence and exercise. He, too, in 
early life, had suffered severe attacks of that disease. Exercise 
may be taken on foot or horseback; gestation in a carriage, or by 
sailing, is not sufficient. Friction by the flesh brush also contri- 
butes to an equal distribution of the fluids, and the healthy excre- 
tions connected with it. Suitable occupation of the mind, in plea- 
sure and business, is no less conducive to health. Dr. Gregory, 
in the winter of 1792-3, informed me that, with all his family 
predisposition to the gout, and, as he supposed, both on the father's 
and mother's side, he had at that time prevented it for about six- 
teen years, by exercise; not yet having much to do in his profes- 
sion, he walked out to Musselborough, a town about five miles 
from Edinburgh. This was not afterwards necessary, for his 
practice became so extensive, that he necessarily led a very active 
life; not so in 1792-3, when he stated to me this fact. But Dr. 
Gregory not only took exercise," he also abstained from wine, and 
was moderate in the use of animal food; by these means he had 
escaped the gout upwards of thirty years, though in early life, in 
the hey-day of youth and its pleasures, he had suffered from it. 
A strong evidence of the good effects of temperance and exercise. 
Cadogan had four fits in his younger days, but, by temperance, 



TREATMENT OF GOUT. 699 

was perfectly freed from it. Dr. Heberden states similar effects 
of abstinence from wine, and the moderate use of animal food. 

The excessive indulgence of the passions should be no less 
guarded against. While Bacchus and Venus are considered as 
the more immediate parents of gout, remember Ci Ira," which 
stands for the passions in general, is put down as the " obstetrix 
arthritidis" — the more immediate agent that brings gout into life. 
Celsus also states that some persons, by abstaining a whole year 
from wine, and venery, have obtained a security from gout 
the remainder of their lives. 

The warm bath I also consider, by its effects upon the surface 
of the body and the secretions in general, among the most effect- 
ual means of prevention. Hence the French are comparatively 
free from gout, though they are celebrated for the stone and the 
pox. So far, then, we may say to our patient on this subject, in 
the language of St. Evremond — " Quod petis in te est." Therein 
the patient must administer to himself. But when this tempe- 
rance and exercise cannot be carried into operation, an occasional 
bleeding — say early in the spring, before the sap rises, and early 
in the autumn, before the cold and other exciting causes are 
applied, and the season of feeding commences, may be found very 
useful in preventing the recurrence of the disease. This practice 
I have in many cases pursued with the best effects. 

An occasional purgative is also useful, not only for depletion, 
but to guard against indigestion, usually preceding the gout, and 
in some instances, its exciting cause. 



FINIS. 



2. 



3/9 U* 



ERRATA. 

The following errors of the press escaped the eye of the Editor, 

or occurred during his absence from the city. Some other minor 

errors, which the intelligent reader will discover and readily 

understand, are not noticed. It is believed none others of any 

consequence will be found in the work. 

Page 50, line 4, for negere, read negare. 

for progressis, read praegressis. 

for yellow fever, read fever. 

for absenthium, read absinthium. 

• '*■ 
for phlegmasia, read phlegmasia^ 

for urine, read urina. 

for turbetse, read turbatae. 

for contagiones, read contagiosus. 

for turbetse, read turbatae. 

for digitori que, read digitosque, 

for nequequam, read nequaquam. 

for ponere disunt, read ponendi sunt; 

for typo, read typho. v 

for utrieorum, read utri eorum. » 

for referenda, read habenda. 

for free, read full. 

for remittent, read excitement. 

for having overlooked forms, read 

being overlooked. 

for of want of, read want of. 

for compounds, read confounds. 

for Parotis, read Parotitis. 



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